Non-helpful relationships with professionals - a literature review of the perspective of persons with severe mental illness

Therapeutic stance towards persons with psychosis - a Grounded Theory study

OBJECTIVE

Over the last decades, psychotherapy of psychosis has increasingly gained attention. The quality of the therapeutic alliance has been shown to have an impact on therapy outcome. Yet, little is know about the influence of the therapeutic stance on the alliance. In this study, we explore psychotherapists' stance towards persons with psychosis with the aim of better understanding its characteristic-hindering and helpful-aspects.

METHOD

6 semi-structured interviews with psychotherapists from three different schools (CBT, PD, ST) were analysed with Grounded Theory. Credibility was checked through external and peer-researcher-supported debriefing.

RESULTS

4 core categories were generated and interrelated in a theoretical model. Therapists' stance was initially characterized by insecurity. Diffent ways of dealing with insecurity yielded different stances: a monological and an open one. A helpful stance was conceived as stemming from openness and was characterized by a dialogical structure. A co-presence (or "dosing") of you and I was conceived as its core aspect.

CONCLUSION

These findings specify the interpersonal dynamics arising from different stances and their impact on the therapeutic alliance and process. Research is still needed to further understand the characteristics of helpful and hindering therapeutic stances, which should also inform the training of psychotherapists.

Pathways to experienced coercion during psychiatric admission: a network analysis

BACKGROUND

In mental health care, experienced coercion, also known as perceived coercion, is defined as the patient's subjective experience of being submitted to coercion. Besides formal coercion, many other factors have been identified as potentially affecting the experience of being coerced. This study aimed to explore the interplay between these factors and to provide new insights into how they lead to experienced coercion.

METHODS

Cross-sectional network analysis was performed on data collected from 225 patients admitted to six psychiatric hospitals. Thirteen variables were selected and included in the analyses. A Gaussian Graphical Model (GGM) using Spearman's rank-correlation method and EBICglasso regularisation was estimated. Centrality indices of strength and expected influence were computed. To evaluate the robustness of the estimated parameters, both edge-weight accuracy and centrality stability were investigated.

RESULTS

The estimated network was densely connected. Formal coercion was only weakly associated with both experienced coercion at admission and during hospital stay. Experienced coercion at admission was most strongly associated with the patients' perceived level of implication in the decision-making process. Experienced humiliation and coercion during hospital stay, the most central node in the network, was found to be most strongly related to the interpersonal separation that patients perceived from staff, the level of coercion perceived upon admission and their satisfaction with the decision taken and the level of information received.

CONCLUSIONS

Reducing formal coercion may not be sufficient to effectively reduce patients' feeling of being coerced. Different factors seemed indeed to come into play and affect experienced coercion at different stages of the hospitalisation process. Interventions aimed at reducing experienced coercion and its negative effects should take these stage-specific elements into account and propose tailored strategies to address them.

A Nursing Process for Shared Decision-Making for Patients with Severe Mental Illness Receiving Treatment Involving Long-Term Coercive Measures: A Modified Grounded Theory Approach

The use of shared decision-making (SDM) has recently attracted attention for building recovery-oriented therapeutic relationships with patients with severe mental illness (SMI). The purpose of this study was to describe a nursing process for SDM for psychiatric patients with SMI being treated via long-term coercive measures, such as seclusion and physical restraint, in the "seclusion room" of a psychiatric ward. The study used a modified grounded theory approach. The participants were 17 psychiatric nurses. Data were collected via semi-structured interviews. Concepts and categories were generated from verbatim transcripts, and their relationships were illustrated using a diagram and by generating a storyline. The nursing process for SDM was based on sensing the response to triggering stimuli, and the nurse-led preventive measures compensated for the patients' lack of coping skills. Because of the patients' persistent instability in response to certain stimuli, in our process, nurses are involved in creating opportunities for self-understanding and self-selection while also taking proactive preventative measures. Patients' reactions to surrounding stimuli were evaluated by nurses, who then determined whether they (or the patient) should take the lead in terms of decision-making.

Exploring Patients' Feeling of Being Coerced During Psychiatric Hospital Admission: A Qualitative Study

Various coercive measures can be used to legally compel a person suffering from psychiatric disorder to undergo treatment. However, evidence suggests that patients' feeling of being coerced is not determined solely by their being submitted to formal coercion. This study aimed to explore voluntary and involuntary patients' experience of coercion during psychiatric hospitalisation and to identify which factors, from their perspective, most affected it. We chose a qualitative design inspired by a hermeneutic-phenomenological approach. Participants were purposively selected from six psychiatric hospitals in Switzerland. Maximum variation sampling was used to ensure the inclusion of patients with different levels of perceived coercion and different admission statuses. In-depth, semi-structured interviews were co-conducted by a research psychologist and a service-user researcher. The transcribed data underwent thematic analysis. All twelve interviewed patients described the hospitalisation as an experience of loss of control over their life due to either external or internal pressures. During the process, perceptions of these pressures varied and sometimes overlapped, leading some patients to describe their admission as a form of simultaneous protection and violation. The balance between these two contradictory feelings was affected by a variety of contextual and relational factors, as well as by the meaningfulness of the experience and the patient's subsequent satisfaction with it. Increasing policy-makers' and clinicians' awareness about the main factors influencing patients' experience of loss of control is of paramount importance in order to develop skills and strategies able to address them, reinforcing patients' empowerment, reducing their feeling of coercion and improving their well-being.

Consumer Views and Experiences of Secondary-Care Services Following REFOCUS-PULSAR Staff Recovery-Oriented Practices Training

BACKGROUND

The use of recovery-oriented practice (ROP) can be challenging to implement in mental health services. This qualitative sub-study of the Principles Unite Local Services Assisting Recovery (PULSAR) project explored how consumers perceive their recovery following community mental health staff undertaking specific ROP training.

METHODS

Using a qualitative participatory methodology, 21 consumers (aged 18-63 years) participated in one-on-one interviews. A thematic analysis was applied.

RESULTS

Four main themes were extracted: (1) connection, (2) supportive relationships, (3) a better life, and (4) barriers. Connections to community and professional staff were important to support consumers in their recovery journey. Many consumers were seeking and striving towards a better life that was personal and individual to each of them, and how they made meaning around the idea of a better life. Barriers to recovery primarily focused on a lack of choice. A minor theme of 'uncertainty' suggested that consumers struggled to identify what their recovered future might entail.

CONCLUSION

Despite staff undertaking the ROP training, all participants struggled to identify language and aspects of recovery in their interaction with the service, suggesting a need for staff to promote open, collaborative conversations around recovery. A specifically targeted recovery resource might facilitate such conversation.

All I missed in the therapeutic relationship: The lived experience narrative of a mental health nurse receiving mental healthcare

WHAT IS KNOWN ON THE SUBJECT?: The therapeutic relationship is crucial for mental health practice, especially to practice that is recovery-orientated. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: This lived experience suggests that mental health professionals can be a long way from knowing the service users' feelings and their precise needs. The narrative reveals how mental health professionals maintain stereotypes and prejudices against people with mental health conditions and how these are reflected in their practice through lack of respect and users' dignity. WHAT ARE THE IMPLICATIONS FOR MENTAL HEALTH NURSING?: This lived experience narrative highlights the need to humanize care.

ABSTRACT

INTRODUCTION: The therapeutic relationship is not always functional in clinical practice due to various factors, such as lack of time, lack of job motivation, exhaustion and rejection towards the person cared for.

AIM

The aim of this study is to illustrate to professionals the needs of the persons they care for and how they see the world.

METHOD

The aim was achieved through the development of a lived experience narrative.

RESULTS

This lived experience narrative describes the experience of a mental health nurse since her first psychotic symptoms and her perceptions of the therapeutic relationship with mental health staff in her trajectory from the first psychiatric appointment until her last contact with the community mental health services.

DISCUSSION

This narrative suggests that mental health professionals are sometimes far from discovering what service users are feeling and their precise needs. This highlights the need to humanize mental healthcare.

Barriers to Client Engagement and Strategies to Improve Participation in Mental Health and Supported Employment Services

OBJECTIVE

A few clients in every mental health center present challenging behaviors, have difficulty engaging in services, and create stress within the treatment team. The authors provided consultations on clients with these characteristics over 4 years in the Social Security Administration's Supported Employment Demonstration (SED).

METHODS

Four experienced community mental health leaders provided consultations on 105 of nearly 2,000 clients receiving team-based behavioral health and employment services in the SED. Using document analysis, consultants coded their notes and identified themes that described barriers to client engagement and strategies teams used to overcome them.

RESULTS

Clients who were difficult to engage experienced complex and interacting behavioral health, medical, and social conditions, which made it hard for therapists to develop therapeutic relationships and help clients find employment. Faced with engagement barriers, staff were often discouraged and felt hopeless about achieving success. To address these barriers, consultants and teams developed several strategies: using supervisors and teammates for support, providing persistent outreach, pursuing referrals and consultations to help with complex conditions, and developing realistic goals.

CONCLUSIONS

Supervisors, team leaders, and consultants in community mental health settings should help staff develop realistic strategies to manage the small number of clients whose behaviors present the greatest challenges. Effective strategies involve providing team-based outreach and support, fostering staff morale, obtaining specialist consultations regarding complex conditions, and calibrating realistic goals.

Trust and collaboration between patients and staff in SUD treatment: A qualitative study of patients’ reflections on inpatient SUD treatment four years after discharge

Background and aim: Substance use disorder (SUD) is multifactorial, complex, and involves the severe problematic use of alcohol, prescription drugs, and other substances. People with SUD have long histories of perceived stigma, marginalisation, exclusion, social isolation, and shame. Moreover, patients with SUD are often treated as untrustworthy and incapable of actively participating in their treatment planning, even by healthcare and social services workers. Methods: Through in-depth interviews with former patients who have undergone SUD treatment, we explored their reflections on the treatment content. Interpretative phenomenological analysis revealed that some informants experienced aspects of the treatment as valuable, whereas others considered the same treatment useless or harmful. Results: Essential aspects of treatment were developing self-esteem and optimism about the future, developing strategies for coping with stress and challenging emotions and situations, developing relationships with family and friends, and preparing for life after inpatient treatment. Relationships with staff were described as crucial in all parts of the treatment. Conclusion: In conclusion, we suggest that a transition to a more collaborative treatment philosophy would be ethically and professionally valuable for providing support and treatment and enhancing patients’ perceptions of empowerment, inclusion, participation, and well-being on their terms, in cooperation with supportive others.

Stigma towards Mental Disorders among Nursing Students and Professionals: A Bibliometric Analysis

Stigma is one of the main barriers to prevention, treatment and recovery from mental illness. However, bibliometric studies in this area are still scarce. Therefore, our aim was to quantify and analyze the scientific literature on the stigma of nursing students and professionals towards mental disorders. To this purpose, bibliometric indicators of scientific production, impact and collaboration were used. Among our results, it stands out that only 14.3% of the total number of studies analyzed measure the efficacy of the interventions carried out to reduce stigma. Furthermore, with exceptions such as Happell B and Byrne L, collaborations between authors and institutions are limited. “Service user involvement” appeared as a prominent keyword in 2018, coinciding with the increase in publications on the effectiveness of interventions. Interventions based on the involvement of people with psychiatric diagnoses in the design of nursing curricula seem to become a promising line of research. More studies measuring the efficacy of such interventions are needed. Knowledge of the lines of research that are being developed and of the researchers and institutions involved can contribute to creating synergy between the different researchers and to continue adding projects to the existing ones, thus contributing to the generation of more robust results that show the most indicated interventions to reduce the still present stigma and improve care for people with psychiatric diagnoses.

Health professionals' perspectives on shared decision-making in secondary mental healthcare: a qualitative study

BACKGROUND

Shared decision-making is widely recommended but has not been widely implemented in mental healthcare. There is a lack of direct evidence about health professionals' perspectives on shared decision-making in Asian cultures, particularly Taiwan. Such knowledge is of key importance to facilitate shared decision-making. Therefore, further studies are needed to clarify this issue.

AIM

To explore health professionals' perspectives of shared decision-making in secondary mental healthcare in Taiwan.

METHOD

Qualitative semi-structured interviews were used. Purposive sampling was applied to recruit health professionals. Data were analysed using thematic analysis.

RESULTS

Twenty-four health professionals were recruited. This study found the absence of shared decision-making was acceptable to them. Barriers included: powerful status of health professionals and families, patients with impaired decisional ability due to mental illness, health professionals' lack of understanding of shared decision-making, and insufficient time. Facilitators included: awareness of patients' right to autonomy and understanding of potential benefits of shared decision-making.

CONCLUSIONS

The study found that the absence of patient involvement in decision-making was widely reported. A discussion of barriers and facilitators is provided. Barriers and facilitators are highlighted to build a foundation for implementing shared decision-making in the future.

Epistemic injustice, children and mental illness

The concept of epistemic (specifically testimonial) injustice is the latest philosophical tool with which to try to theorise what goes wrong when mental health service users are not listened to by clinicians, and what goes right when they are. Is the tool adequate to the task? It is argued that, to be applicable at all, the concept needs some adjustment so that being disbelieved as a result of prejudice is one of a family of alternative necessary conditions for its application, rather than a necessary condition all on its own. It is then argued that even once adjusted in this way, the concept does not fit well in the area where the biggest efforts have been made to apply it so far, namely the highly sensitive case of adult patients suffering from delusions. Indeed it does not serve the interests of service users struggling for recognition to try to apply it in this context, because there is so much more to being listened to than simply being believed. However, the concept is found to apply smoothly in many cases where the service users are children, for example, in relation to children's testimony on the efficacy of treatment. It is suggested that further research would demonstrate the usefulness of the concept in adult cases of a similar kind.

"We're Working in a Trauma Avoidant Culture": A Qualitative Study Exploring Assertive Community Treatment Providers' Perspectives on Working with Trauma and PTSD in People with Severe Mental Illness

Assertive Community Treatment (ACT) is the most widely used evidence-based community mental health intervention for people with severe mental illness (SMI). Despite research showing that the vast majority of those with SMI have traumatic histories, the ACT service model does not have consistent guidelines on how to address trauma in their client population. This study employed thematic-analysis through interviewing ACT providers to better understand their perspectives on working with trauma in clients. Five overarching themes with 21 sub-themes emerged: the role and scope of ACT teams and model regarding trauma, discussions of trauma with clients, current treatment of trauma, barriers to working with trauma, and recommendations for enabling trauma discussions and treatment. Some examples for recommendations were: a need for more training regarding trauma, increasing resources like including a psychologist and trauma specialized professionals on the team, more support from leadership, and a cultural change from medicalization. Implications of the barriers and suggestions are discussed.

A qualitative emancipatory inquiry into relationships between people with mental disorders and health professionals

WHAT IS KNOWN ON THE SUBJECT?: A therapeutic alliance with people with mental disorders could help increase the efficacy of treatment. The paradigm shift from a paternalistic model to one that respects the person's autonomy has led to professionals accepting the active role of people with mental disorders making decisions that affect their treatment. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: People with mental disorders perceive paternalistic and stigmatizing attitudes from health professionals, and they do not feel involved in decisions about their health, which can render effective therapeutic alliances difficult. The findings reveal that although people in Mediterranean countries are used to paternalistic treatment from health professionals due to cultural factors, people with mental disorders are increasingly critical of how they are treated and demand greater autonomy and respect in the decision to undergo drug therapy. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: In their interactions with people with mental disorders, health professionals should include efforts aimed at improving shared decision-making capabilities and avoiding paternalistic or stigmatizing attitudes. ABSTRACT: Introduction A therapeutic alliance with people is essential for the efficacy of treatments. However, the traditional paternalistic values of the Mediterranean society may be incompatible with patient autonomy. Aim To explore the therapeutic relationship from the perspective of people diagnosed with mental disorders with health professionals, including nurses. Methods This emancipatory research was performed through focus groups, with people with mental disorders who had a variety of diagnoses and experiences of acute and community-based mental health services and other healthcare services. Data were analysed using the content analysis method. Results Four main themes emerged: stereotypes and prejudice; quality of interactions and treatment; emotional and behavioural impacts; and demands. Discussion According to the participants' descriptions, health professionals are not exempt from prejudice against persons with psychiatric diagnoses. They reported experiencing abuse of power, malpractice, and overmedication. Thus, in the Mediterranean culture, professional attitudes may represent a barrier for an appropriate therapeutic alliance, and people with mental disorders do not feel involved in making decisions about their health. Implications for practice Knowing how people with mental disorders perceive their interactions with health professionals and the effects is necessary to move the care model towards more symmetric relationships that facilitate a therapeutic alliance.

Therapists' Experience of Video Consultation in Specialized Mental Health Services During the COVID-19 Pandemic: Qualitative Interview Study

Background

As part of political and professional development with increased focus on including service users within mental health services, these services are being transformed. Specifically, they are shifting from institutional to noninstitutional care provision with increased integration of the use of electronic health and digitalization. In the period from March to May 2020, COVID-19 restrictions forced rapid changes in the organization and provision of mental health services through the increased use of digital solutions in therapy.

Objective

The aim of this study was to develop and advance comprehensive knowledge about how therapists experience the use of video consultation (VC). To reach this objective, we evaluated therapists’ experiences of using VC in specialized mental health services in the early phase of COVID-19 restrictions. The following questions were explored through interviews: Which opportunities and challenges appeared when using VC during the period of COVID-19 restrictions? In a short-term care pathway, for whom does VC work and for whom does it not work?

Methods

This study employed a qualitative approach based on an abductive strategy and hermeneutic-phenomenological methodology. Therapists and managers in mental health departments in a hospital were interviewed via Skype for Business from March to May 2020, using a thematic interview guide that aimed to encourage reflections on the use of VC during COVID-19 restrictions.

Results

Therapists included in this study experienced advantages in using VC under circumstances that did not permit face-to-face consultations. The continuity that VC offered the service users was seen as a valuable asset. Various negative aspects concerning the therapeutic environment such as lack of safety for the most vulnerable service users and topics deemed unsuitable for VC lowered the therapists’ overall impression of the service. The themes that arose in the data analysis have been categorized in the following main topics: (1) VC—“it’s better than nothing”; (2) VC affects therapists’ work situation—opportunities and challenges in working conditions; and (3) challenges of VC when performing professional assessment and therapy on the screen.

Conclusions

Experiences with VC in a mental health hospital during COVID-19 restrictions indicate that there are overall advantages to using VC when circumstances do not permit face-to-face consultations. Nevertheless, various negative aspects in the use of VC lowered the therapists’ overall impression of VC. Further qualitative research is needed, and future studies should focus on service users’ experiences, cocreation between different stakeholders, and how to scale up the use of VC while ensuring that the service provided is appropriate, safe, and available.

Diversity, Complexity and Ordinality: Mental Health Services Outside the Institutions-Service Users' and Professionals' Experience-Based Practices and Knowledges, and New Public Management

In conjunction with the dismantling of psychiatric hospitals, social workers have been commissioned to help service users in their daily living in their homes and in the community. The consequences of these changes for experience-based knowledge and practices in their contexts remain relatively unknown. In this study, eighteen service users and the social workers they described as helpful for them were interviewed. The interviews were recorded, transcribed, and analyzed using Thematic Analysis. The following themes emerged: “Here, there and everywhere”, “Doing, being, becoming”, “Talking” and “Order, planning and improvisation” concerning the contradictions service users and professionals mentioned about their practices and the conditions imposed by managerial methods connected to New Public Management. Finally, “Spontaneous planned complexity” was chosen as our overarching theme to characterize the new knowledge and practices which have been developed. The displacement of the place for the encounter and the introduction of non-medicalized professions have allowed community-based practices and thus the co-creation and emergence of new knowledge about the service users as persons and the professionals as qualified professionals. The challenge remains for managers to have trust in their colleagues and not impose rigid rules, schematized methods, and repeated controls.

Micro-affirmations and Recovery for Persons with Mental Health and Alcohol and Drug Problems: User and Professional Experience-Based Practice and Knowledge

Recurrent factors contributing to a recovery process from co-occurring mental health and addiction problems mentioned by users and professionals have been analyzed as part of working alliances and helpful relationships. Still, we lack knowledge about how helpful relationships are developed in daily practice. In this article, we focus on the concrete construction of professional helpful relationships. Forty persons in recovery and fifteen professionals were interviewed. The interviews were analyzed according to thematic analysis, resulting in three themes presented as paradoxes (1) My own decision, but with the help of others; (2) The need for structures and going beyond them; and (3) Small trivial things of great importance. Micro-affirmations have a central role in creating helpful relationships by confirming the individuals involved as more than solely users or professionals. More attention and appreciation should be paid to practices involving micro-affirmations.

Le dévoilement de soi dans la recherche d’aide et le suivi dans les services de santé mentale et psychiatrie

Le dévoilement de soi des patients est essentiel au travail des professionnels de la santé, et ceci est encore plus critique en santé mentale où la parole du patient est le reflet du contenu de la psyché. Le dévoilement de soi concerne alors des symptômes invisibles qui sont associés à des problèmes de santé où la discrimination et la stigmatisation sont encore très présentes. Cet article explore les enjeux éthiques de ce phénomène encore très peu étudié. Le dévoilement en tant que processus décisionnel, interpersonnel, dynamique et complexe sera défini et approfondi à l’aide d’exemples tirés de la recherche. Par la suite, la vulnérabilité de la personne qui se dévoile sera abordée, suivie des enjeux liés aux normes de pratique professionnelle associées au dévoilement des patients et à leur responsabilité avers celui-ci. Ces éléments mettent en lumière de nombreuses questions éthiques et nous amènent, en dernier lieu, à une amorce de proposition pour positionner les professionnels impliqués.

'Like a human being, I was an equal, I wasn't just a patient': Service users' perspectives on their experiences of relationships with staff in mental health services

OBJECTIVES

The quality of therapeutic relationships in psychiatric services has a significant impact upon the therapeutic outcomes for people diagnosed with a severe mental illness. As previous work has not explicitly explored service users' in-depth views about the emotional impact of these relationships, the objective of this work was to bring this perspective to the fore and to gain a greater understanding about which relational components can lead to psychological change.

DESIGN

The project was conducted alongside a service user organization. An interview design was used to qualitatively explore service users' experiences and perceptions of their relationships with mental health practitioners.

METHODS

Eight individuals who had experience of the mental health system in the United Kingdom were interviewed. Interpretative phenomenological analysis was used to analyse the data.

FINDINGS

Three superordinate themes emerged from the analysis. These were (1) Trying to survive: am I a person or just an object in the system?; (2) Traumatic experiences within relationships; and (3) Helpful and transformative relationships. Further, the key transformative components of these relationships were power, safety, and identity.

CONCLUSIONS

Mental health services should be more focused upon care, rather than control. The Power Safety Identity (PSI) model, a reflexive model based upon key relational components highlighted by participants, is proposed for services and professionals to consider their work. The components of this model are managed by mental health practitioners and can determine whether these relationships maintain, increase, or alleviate psychological distress.

PRACTITIONER POINTS

Awareness of the relational components of power, safety, and identity has the potential to help practitioners reflect upon the tensions they experience in their relationships with service users. Mental health services and professionals that are sensitive to issues related to power, safety, and identity when responding to the needs of the service users can improve how individuals perceive the quality of care provided by them. Relationships between service users and mental health practitioners can encourage recovery if they are consistent, safe, trusting, provide protective power, and mirror a positive sense of self.

Patients' perspectives on shared decision making in secondary mental healthcare in Taiwan: A qualitative study

OBJECTIVE

The aim of this study is to explore patient perspectives on shared decision making in secondary mental healthcare in Taiwan.

METHODS

Qualitative semi-structured interviews were used to explore patient perspectives on shared decision making in secondary mental healthcare in Taiwan. Individual semi-structured interviews were conducted from July to August 2017 with a purposive sample of twenty patients using halfway houses. Data were analysed using thematic analysis.

RESULTS

Analysis of the interviews identified two themes: barriers to shared decision making; facilitators of shared decision making. Patients perceived that they were not involved in decision making due to: the professional status of health professionals; negative perception of making decisions; and limited time resources. However, patients reported a desire to be involved and felt sufficient information exchange would be a necessary step towards collaboration/sharing decisions about treatment with clinicians.

CONCLUSION

The findings provided an understanding of significant barriers to and facilitators of implementing shared decision making to aid further professional training and the development of national policies.

PRACTICE IMPLICATIONS

The findings could be the basis for developing effective strategies to overcome barriers to shared decision making and improve the process quality of delivering shared decision making.

Determinants of Therapeutic Alliance With People With Psychotic Disorders: A Systematic Literature Review

Therapeutic alliance determines medical treatment adherence, the success of psychotherapy, and the effectiveness of care. This systematic review aims at better understanding its determinants. The electronic databases Pubmed, Cochrane Library, and Web of Science were searched, using combinations of terms relating to psychosis and therapeutic alliance. Studies were selected and data were extracted using a PRISMA statement. Forty-one studies were selected, including 20 cross-sectional studies, 10 cohort studies, five randomized controlled trials, four literature reviews, and two retrospective studies. The quality of therapeutic alliance correlates with clinical symptoms, insight, social and family support, the therapist's qualities, the availability of shared therapeutic decision making, and the types of hospitalization. Although current evidence needs to be completed with further studies, it is already clear that group and family psychoeducation, cognitive remediation, community-based psychiatric services, and shared therapeutic decision making are essential approaches in the management of patients with psychosis.

Beyond formalized plans: User involvement in support in daily living - users' and support workers' experiences

BACKGROUND

User involvement, based on respect and carried out through dialogue, has been shown to lead to increased self-respect, self-confidence and positive identity. In Sweden, the Social Service Act requires that interventions be designed and implemented together with the individual concerned. The basic criterion for social support is prolonged severe mental illness (usually at least 6 months), with no criteria for specific diagnosis or institutional history. The most common form of social support is 'support in daily living', a community care intervention for people aged 18 years or older who have their own homes and living arrangements.

AIM

This article aims to deepen our understanding of user involvement at the individual level in the provision of an ongoing social work intervention. What elements of user involvement can be found in users' and support workers' descriptions of helpful support in daily living?

METHOD

Qualitative interviews were conducted with 18 users, who had experienced support in daily living as helpful, and 16 interviews with the users' support workers.

RESULTS

Three major, interconnected themes emerged: Constant dialogue; Framing the flexibility, in relation to formalized intervention plans and regulations; The importance of 'small things', decisions concerning daily life.

CONCLUSION

Both users and support workers described user involvement at the individual, micro-level to be an integral part of helpful support in daily living. It was possible to create a space for dialogue and co-creation in which users were involved in formulating and deciding the contents of their support at an informal level, to influence their own everyday lives. While a formal framework of rules, restrictions and plans surrounds meetings between users and professionals, a facilitating factor may be the absence of too detailed plans and regulations, leaving trust to users and professionals and their capacity to manage most of the choices they have to make.

"How do we use the time?" - an observational study measuring the task time distribution of nurses in psychiatric care

Background

The nurse’s primary task in psychiatric care should be to plan for the patient’s care in cooperation with the patient and spend the time needed to build a relationship. Psychiatric care nurses however claim that they lack the necessary time to communicate with patients. To investigate the validity of such claims, this time-motion study aimed at identifying how nurses working at inpatient psychiatric wards distribute their time between a variety of tasks during a working day.

Methods

During the period of December 2015 and February 2016, a total of 129 h and 23 min of structured observations of 12 nurses were carried out at six inpatient wards at one psychiatric clinic in southern Sweden. Time, frequency of tasks and number of interruptions were recorded and analysed using descriptive statistics.

Results

Administering drugs or medications accounted for the largest part of the measured time (17.5%) followed by indirect care (16%). Relatively little time was spent on direct care, the third largest category in the study (15.3%), while an unexpectedly high proportion of time (11.3%) was spent on ward related tasks. Nurses were also interrupted in 75% of all medication administering tasks.

Conclusions

Nurses working in inpatient psychiatric care spend little time in direct contact with the patients and medication administration is interrupted very often. As a result, it is difficult to establish therapeutic relationships with patients. This is an area of concern for both patient safety and nurses’ job satisfaction.

Understanding barriers and facilitators to therapeutic relationships in state psychiatric hospitals

OBJECTIVE(S)

This qualitative study aimed to elucidate barriers and facilitators faced by individuals with serious mental illness in establishing positive therapeutic relationships within the public sector.

METHOD

Twenty-two individuals, receiving inpatient treatment and near discharge from three state psychiatric facilities, participated. The sample was diverse with respect to gender (60 % male) and race/ethnicity, with a mean age of 40 years (standard deviation = 12.91). Thematic analysis and a contextualist lens were used to analyze the data.

RESULTS

Results indicated that inadequate meeting time, lack of clinically relevant communication, and discrepancies in client/provider perspectives, impeded positive therapeutic relationships. Facilitators to therapeutic relationships included feelings heard and understood by providers, comprehensive, timely discharge plans, and thinking broadly about aftercare.

CONCLUSIONS

Cultivating positive therapeutic relationships is especially difficult in resource-challenged settings. Enhanced client-provider communication and individually tailored aftercare planning can enhance inpatient therapeutic relationships, convey a greater sense of understanding of clients, and facilitate client-provider collaboration.

General Medical Clinicians' Attitudes Toward People with Serious Mental Illness: A Scoping Review

Individuals with serious mental illness (SMI) experience significant premature mortality due to somatic conditions but often receive sub-optimal somatic care, but little research has been done to understand how general medical clinicians' attitudes may affect care provision or health outcomes. This review describes general medical clinicians' attitudes toward people with SMI, compares these attitudes to attitudes among mental health clinicians or toward individuals without SMI, and examines the relationship between attitudes and clinical decision making. Seventeen studies were reviewed. General medical clinicians reported negative attitudes toward individuals with SMI. These attitudes were generally more negative than attitudes among mental health clinicians and were consistently more negative when compared to attitudes toward individuals without SMI. Four studies suggest that these negative attitudes have an adverse effect on clinician decision making.

Effectiveness of direct contact intervention with people with mental illness to reduce stigma in nursing students

People with mental illnesses are at a higher risk than the general population of suffering from somatic diseases. However, they receive less attention from healthcare services. Some studies have indicated that this situation can be partially explained by the stigmatizing attitudes of health professionals, including nurses. With the objective to improve future nursing professionals' attitudes towards people with mental illnesses, an intervention involving direct contact with people who had lived experience with mental illnesses was designed and its effectiveness was measured. It consisted of a single 90-min session involving a mental health professional, a person with a mental illness, and a family member of someone with a mental illness. The intervention was based on a structured script where they described their experiences with the illness and their history of recovery, and then, they had a discussion with the attendees. The effectiveness of this approach was measured through a quasi-experimental study with a pretest-post-test design. The differences in the scores obtained in the AQ-27-E questionnaire before and after the intervention indicated that there was a decrease in fear, feelings of danger, avoidance, segregation, and coercive attitudes, while positive feelings increased, including a tendency to help and compassion. These results are important for clinical practice because this intervention could improve the quality of care provided to people with mental illnesses.

Small Things, Micro-Affirmations and Helpful Professionals Everyday Recovery-Orientated Practices According to Persons with Mental Health Problems

The aim of this study is to present concrete descriptions of the content in the construction of helpful relationships with staff, according to users. Starting with the re-occurring concept of the meaning of "little things" in recovery studies, a literature review was done. A thematic analysis shows that small things play an important role in improving a person's sense of self. Small things seem to be an invisible but effective parts of a recovery-orientated practice, but they might be defined as unprofessional and their efficacy negated.

Educational nurse-led lifestyle intervention for persons with mental illness

Although persons with severe mental illness face an increased risk of mortality and of developing negative health outcomes, research has shown that lifestyle interventions can sufficiently support their health. In response, this study examined a nurse-led lifestyle intervention developed in cooperation with members of municipal and county councils to gauge its impact on the quality of life, cognitive performance, walking capacity, and body composition of persons with severe mental illness. Lasting 26 weeks and involving 38 persons with severe mental illness, the intervention prioritised two components: the interpersonal relationships of persons with severe mental illness, staff, and group leaders and group education about physical and mental health. Pre-post intervention measurements of quality of life collected with the Manchester Short Assessment of Quality of Life, cognitive performance with the Frontal Systems Behaviour Scale, walking capacity with a 6-min walk test, and body composition in terms of waist circumference and body mass index were analysed using a nonparametric test Wilcoxon signed-rank test. Results suggest that the intervention afforded significant improvements in the health-related variables of quality of life, cognitive performance, walking capacity, and waist circumference for persons with severe mental illness. However, long-term studies with control groups and that examine parameters related to cardiovascular risk factors are essential to ensure the sustained impact of the intervention.

Exploring Working Relationships in Mental Health Care via an E-Recovery Portal: Qualitative Study on the Experiences of Service Users and Health Providers

BACKGROUND

The quality of working relationships between service users and health providers is fundamental in the processes of recovery in mental health. How Internet-based interventions will influence these relationships for persons with long-term care needs, and the measures that can be taken to maintain and enhance working relationships through Internet, is still not well understood.

OBJECTIVE

The aim of this study was to gain insights into how service users and health providers experience their working relationships when they are offered the option of supplementing ongoing collaboration with an e-recovery portal.

METHODS

In this exploratory and descriptive study, an e-recovery portal was used by service users and their health providers in 2 mental health communities in Norway for at least 6 months and at most 12 months (2015-2016). The portal consists of secure messaging, a peer support forum, and a toolbox of resources for working with life domains including status, goals and activities, network map, crisis plan, and exercises. The portal was owned and managed by the service user while health providers could remotely access parts of the service user-generated content. The participants could use the portal in whatever way they wished, to suit their collaboration. Data from 6 focus groups, 17 individual interviews, and an interview with 1 dyad about their experiences of use of the portal over the study period were inductively coded and thematically analyzed.

RESULTS

The thematic analysis resulted in 2 main themes: (1) new relational avenues and (2) out of alignment, illustrated by 8 subthemes. The first main theme is about dyads who reported new and enriching ways of working together through the portal, particularly related to written communication and use of the goal module. Illustrative subthemes are ownership, common ground, goals and direction, and sense of presence and availability. The second main theme illuminates the difficulties that arose when service users' and health providers' expectations for portal use were not aligned, and the consequences of not addressing these difficulties. Illustrative subthemes are initiative and responsibility, waiting for the other, feeling overwhelmed, and clarifications and agreements.

CONCLUSIONS

The degree to which dyads benefited from using the e-recovery portal appeared to be mainly associated with the degree to which the dyads' relations were open and flexible before the portal was introduced. For those who experienced frustrations, the portal may have both exposed and added to suboptimal working relationships. Use of the goal module appeared to strengthen the person-centered nature of collaboration. A key question is how health providers balance between enabling service users' greater control over their care, without relinquishing responsibility for the quality of the working relationship, also when using an e-recovery portal. Implications for implementation are discussed.

Dependence and resistance in community mental health care-Negotiations of user participation between staff and users

WHAT IS KNOWN ON THE SUBJECT?: Implementation of user participation is described as a change from a paternalistic healthcare system to ideals of democratization where users' voices are heard in relational interplays with health professionals. The ideological shift involves a transition from welfare dependency and professional control towards more active service-user roles with associated rights and responsibilities. A collaborative relationship between users and professionals in mental health services is seen as important by both parties. Nevertheless, the health professionals find it challenging in practice to reorient their roles and to find productive ways to cooperate. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: This study illuminates how user participation is negotiated and involves multiple and shifting subject positions in the collaboration between users and professionals in community mental health care. By taking different positions, the relationship between users and professionals develops through dynamic interaction. This study challenges understandings of equality and implicit "truths" in user participation by illuminating subtle forms of power and dilemmas that arise in user-professional negotiations. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Instead of denying the appearance of power, it is important to question the execution of power in the interplay between users and professionals. Focusing on the negotiation processes between users and professionals is important for increasing reflection on and improving understanding of the dynamic in collaboration and speech. By focusing on negotiations, power can be used in productive ways in user-professional relationships.

ABSTRACT

Introduction Implementation of user participation is considered important in today's mental health care. Research shows, however, that user participation lacks clarity and provokes uncertainty regarding shifting roles. Aim To investigate negotiation of user participation in a microstudy of interplay between users and health professionals in community mental health care. Method This qualitative study is based on semi-structured in-depth interviews, involving ten service users and ten professionals in community mental health care in Norway. The analysis is inspired by Willig's model for Foucauldian discourse analysis. Results The study illuminates the dynamic nature of user participation that arises through negotiation between users' and professionals' positions as change enablers, dependents, resisters, persuaders and knowledge holders. Discussion Discourses of user participation allow for different subject positions in mental health care. User participation also involves government and questions of power, as well as ambitions of change and control. Professionals act in different ways to make and keep users active, participating, enterprising and self-governing, and users respond and take part within the same discursive framework. Implications for practice Awareness of subjects' positions in discourses is important to increase reflection on the dynamic interplay in user-professional collaboration.

Help-Seeking in Suicidal Situations: Paramount and yet Challenging. Interactions between Significant Others of Suicidal Persons and Health Care Providers

Significant others are often crucial for suicidal persons or suicide attempters' access to care, yet little is known about their efforts to seek help. This article presents the findings of a qualitative pilot study carried out in Switzerland on the help-seeking process of 18 significant others, their perception of the care received by their loved one, and the interactions and collaboration they experienced with professionals. Most significant others repeatedly sought out support for their loved one and themselves. The help-seeking process seemed mostly difficult, was seldom successful on the first attempt, and was filled with multiple difficulties, such as availability and continuity of care and cooperation issues with professionals. Two-thirds of participants were not satisfied with the care provided to their loved ones and half of them faced challenges in their cooperation with professionals, i.e., poor sharing of information or not being acknowledged as partners or supported by professionals. Based on their experience, providing education about suicidal crises and care programs to significant others might lighten their burden and improve their cooperation with professionals, who in turn may benefit from training in communication issues and specific methods of cooperation with significant others in suicidal situations.