Strategic Storytelling: An Exploration of the Professional Practices of Mental Health Peer Providers

"I Will Die by My Own Hand": Understanding the Development of Suicide Capability in the Narratives of Individuals Who Have Attempted Suicide

Suicide capability is a multidimensional concept that facilitates the movement from suicidal ideation to suicide attempt. The three-step theory of suicide posits that three overarching contributors comprise suicide capability: acquired (fearlessness about death and high pain tolerance), dispositional (genetics), and practical (knowledge and access to lethal means) capability. Although extensive research has investigated relationships between individual contributors of capability and suicide attempts, little research has considered how an individual's capability for suicide develops as a combination of contributors. Given suicide is multifaceted and complex, our understanding of capability development is relatively limited. This potentially negatively impacts prevention and capacity reduction-focused intervention efficacy. Therefore, this study aimed to explore how suicide capability develops. Fourteen community-based suicide attempt survivors were recruited using convenience sampling. Individual narratives were collected using open-ended interviews, and data were analysed using narrative analysis. Results indicated that participant narratives contained two elements. The first included how capability development and suicide attempt facilitation were often underpinned by the relational interplay between acquired and practical contributors. For example, participants without a high pain tolerance seeking attempt methods that were perceived to be painless. The second element contained a novel finding relating to the agentic role of participants when deciding and attempting suicide. Agency was revealed within and across narratives emphasising the active role the individual plays in their movement from ideation-to-action. The role of individual agency in coming to a decision to take one's own life and then acting warrants further consideration within contemporary suicide theories.

Exploring the Self-Care Factors for Recovery in Alcohol Use Disorder and the Role of Peer Recovery Coaches: A Qualitative Study

Self-care is important in addiction recovery, and peer recovery coaches (PRCs) play key roles in recovery. This qualitative study explored self-care factors for individuals recovering from alcohol use disorder and the role of PRCs in supporting these individuals' self-care. Individual interviews with five PRCs and five workers in community addiction management centers in South Korea were performed. Data were analyzed using content analysis. Two categories and six subcategories were derived. The two categories were "elements of self-care: preparation and practice for a new way of life" and "the roles of PRCs: recovery facilitators with differentiated competencies." The factors identified as being involved self-care were summarized as "changing one's thought process and attitude" and "practical enactment considering the situation." The effective roles of PRCs were "sharing specific and realistic information," "providing motivation," "building empathy," and "presenting role models as mentors." This study identified self-care factors that should be included in addiction recovery programs with the participation of PRCs and also identified the roles of the PRCs. Developing and applying nursing interventions with PRCs in clinical and community nursing settings is necessary.

Seeing Your Stories: Visualization for Narrative Medicine

Importance: Narrative medicine (NM), in which patient stories play a crucial role in their diagnosis and treatment, can potentially support a more holistic approach to patient care than traditional scientific ones. However, there are some challenges in the implementation of narrative medicine, for example, differences in understanding illnesses between physicians and patients and physicians' increased workloads and overloaded schedules. This paper first presents a review to explore previous visualization research for narrative medicine to bridge the gap between visualization researchers and narrative medicine experts and explore further visualization opportunities. Highlights: The review is conducted from 2 perspectives: (a) the contexts and domains in which visualization has been explored for narrative medicine and (b) the forms and solutions applied in these studies. Four applied domains are defined, including understanding patients from narrative records, medical communication, medical conversation training in education, and psychotherapy and emotional wellness enhancement. Conclusions: A future work framework illustrates some opportunities for future research, including groups of specific directions and future points for the 4 domains and 3 technological exploration opportunities (combination of narrative and medical data visualization, task-audience-based visual storytelling, and user-centered interactive visualization). Specifically, 3 directions of future work in medical communication (asynchronous online physician-patient communication, synchronous face-to-face medical conversation, and medical knowledge dissemination) were concluded.

A Two-Phase Qualitative Enquiry Into Storytelling's Potential to Support Palliative Care Patient-Led Change, Using a Systematic Review Approach

A terminal diagnosis can diminish an individual's sense of agency and identity. Leading change appears to restore a sense of agential self. The first phase of this literature review explores factors influencing patient-led change across the palliative care ecosystem. The second phase illuminates how storytelling can support palliative care patients in leading ecosystem-wide change. 35 studies were identified in Phase 1 and 36 in Phase 2. This research highlights the need to situate patient leadership activity within a palliative care ecosystem to understand factors likely to support or hinder patient leadership activity within it. The evidence indicates the potential use of storytelling to support patients with a life-limiting illness to lead change across the palliative care ecosystem. This challenges current conceptualisations of such patients and offers them instead as an additional source of palliative care support.

Adding online storytelling-based acceptance and commitment therapy to antidepressant treatment for primary care patients: a randomized clinical trial

Depression is most often treated in primary care, where the prevailing treatment is antidepressant medication. Primary care patients with depression are less likely to be exposed to psychosocial interventions, despite evidence suggesting many of these treatments are effective. An example is acceptance and commitment therapy (ACT), a behavioral treatment for depression with a growing evidence base. A self-guided ACT intervention with a peer narrative (i.e. storytelling) format was developed with the intention of creating a treatment option for primary care patients that was more accessible than traditional psychotherapy. Titled LifeStories, the online program features videos of real individuals sharing coping skills for depression based on lived experiences and key ACT principles. A total of 93 primary care patients taking antidepressants were randomized to either continued antidepressant treatment alone or antidepressant treatment plus LifeStories for 4 weeks. There were no differences over time on depression severity and psychological inflexibility. However, LifeStories led to greater improvements in quality of life and increased patients' interest in additional treatment compared to antidepressant medication alone.Clinical trial pre-registration: ClinicalTrials.gov (NCT04757961).

The role of patients' stories in medicine: a systematic scoping review

BACKGROUND

Patients' stories provide Palliative Care physicians with a glimpse into the former's lives and their psycho-emotional, sociocultural, and contextual considerations. Yet, few physicians are trained to interpret and apply patients' stories in their practice. Inherent variability in how stories are transmitted and interpreted raises questions over their potential effects on care. Amidst a dearth of accounts in Palliative Care, we map current use of patient stories to guide the training, assessment, and oversight of this 'care influencing' practice in medicine.

METHODS

This systematic scoping review was guided by the Systematic Evidence-Based Approach (SEBA) to ensure a reproducible and structured approach. The themes and categories identified through the Split Approach's concurrent and independent thematic and directed content analyses provided a comprehensive sketch of the included articles. The Jigsaw Perspective combined the themes and categories identified. The last stage of SEBA compared these results with two recent reviews of storytelling to ensure consistency of the domains created that guided the discussion.

RESULTS

Ten thousand two hundred seven articles were reviewed, 963 full text articles were evaluated, and 199 articles were included. The four domains identified were study characteristics, benefits, approaches, and positive effects and concerns.

CONCLUSION

Stories support patient-centered, personalized, and holistic clinical care. However, variability in the stories, their interpretations and use in care decisions underscore the need for further study on the structuring, teaching, assessing, and delivery of this 'care influencing' practice.

Supervision of the mental health lived experience workforce in Australia: A scoping review

The mental health Lived Experience workforce (also referred to as peer workforce) is growing rapidly internationally and within Australia. Peer workers are increasingly employed within multi- and inter-disciplinary teams, often directly supervised by mental health professionals such as nurses. Professional supervision has been identified as fundamental for implementing a sustainable peer workforce, but significant gaps in the literature remain, in particular, an understanding of appropriate supervision practices. This scoping review synthesized academic and grey literature on Lived Experience supervision in Australia, exploring current thoughts on best practices. Four electronic databases were searched, and grey literature was located via Google Advanced searches, contacting Lived Experience experts and conducting web-based desktop searches of key mental health organization websites. Thematic analysis identified and described key characteristics in relation to how supervision is conceptualized and operationalized. Eight peer-reviewed and 46 grey literature documents describing supervision and supervisory practices were analysed. Of these studies, 26 were Lived Experience-led. Analysis revealed four key themes: (i) defining peer supervision, (ii) variability in understanding the purpose of supervision, (iii) approaches to supervision and the need for choice and flexibility, and (iv) qualities and skills of the supervisor. Additionally, the establishment of a national professional organization for peer workers was highlighted to protect the authenticity of Lived Experience roles and develop an effective workforce. Clearly, a sustainable Lived Experience workforce cannot develop in isolation, and mental health nurses, as important allies in mental healthcare, need to work alongside, plan and advocate for appropriate supervision practices for this emerging workforce.

Peer-Facilitated Decision Making in Mental Health: Promises, Pitfalls, and Recommendations for Research and Practice

Recognition has grown that peer support workers serve an important role in facilitating decision making about treatment and recovery among people with mental health conditions. This article provides examples of peer-facilitated decision support interventions in the literature, discusses promises and potential pitfalls associated with peers serving in decision support roles, and offers recommendations for research and practice. Examples were selected from the literature on decision support interventions for people with serious mental illnesses, such as schizophrenia, bipolar disorder, and major depression. Promises, pitfalls, and recommendations were informed by this research and by the literature on lived experience perspectives, the helper-therapy principle, and reported barriers to and facilitators of peers assisting with decision making. According to the included studies, peers may facilitate decision making in several ways (e.g., by asking service users about their goals or preferences, assisting them with using decision support tools, sharing stories, and facilitating access to information and resources). Peer-facilitated decision support may be associated with positive decision making and health outcomes for service users and peer support workers. However, providers need to carefully consider barriers to implementation of this support, such as inadequate resourcing, poor integration, and compromising of peer support values.

'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.

Common Humanity as an Under-acknowledged Mechanism for Mental Health Peer Support

Mental health peer support (PS) is a relational approach to recovery. Service users are helped through a relationship focused on connection with a PS worker who shares similar experiences. Despite the strong evidence base, the mechanisms of action for mental health PS are under-researched. Several theories have been proposed to explain the mechanisms, including social comparison theory (SCT). SCT highlights the benefits arising from emphasising differences between a service user and the PS worker. An unintended consequence is that connection between them may be reduced. We propose common humanity (CH) as an under-acknowledged mechanism of action. CH is an experience recognising that there are other people living with similar suffering, and helps us regulate emotions. A CH-informed connection-based PS relationship may help a service user in different ways from a SCT-informed comparison-based PS relationship. Future PS research can investigate emotional self-regulation to establish whether CH-related outcomes arise from PS.

Living Kidney Donation Stories and Advice Shared Through a Digital Storytelling Library: A Qualitative Thematic Analysis

Rationale & Objective

Despite the development of numerous educational interventions, there has been limited change in actual living donor kidney transplant (LDKT) rates over time. New strategies, such as the inclusion of patient stories in patient education, show promise to inspire more people to donate kidneys. This study identified the challenges faced, coping strategies used, and advice shared by transplant donors and recipients.

Study Design

Qualitative thematic analysis.

Setting & Participants

One hundred eighteen storytellers across the United States and Canada, including 82 living donors and 36 kidney recipients of living donor transplants who shared their stories on the Living Donation Storytelling Project (explorelivingdonation.org), an online digital storytelling platform and library.

Analytical Approach

A poststorytelling survey assessed participant demographics. Two coders conducted tool-assisted (Dedoose v.8.3.35) thematic analysis on narrative storytelling videos and transcripts.

Results

Storytellers were predominantly White (79/118, 66.95%), female (76/118, 64.41%), and non-Hispanic (109/118, 92.37%) with college/vocational education (50/118, 42.37%). Common themes were found related to living donation challenges for donors and recipients (eg, the fear of not being able to complete the LDKT process, of unsupportive family or rejected donation requests, and of unknown or adverse surgical outcomes and graft rejection) and recommended coping strategies (eg, seeking LDKT information, using prayer, and relying on a support network). Recipients provided advice that included being proactive and staying hopeful, whereas donors recommended seeking support, researching LDKT to comprehensively learn, and building a community of support.

Limitations

Limited representation of diverse demographics.

Conclusions

Although supplementary to traditional education about LDKT, digital storytelling provides a source of peer support that can enhance the experience of donors and recipients and encourage autonomy and self-management after transplant.

Negotiating mental illness across the lay-professional divide: Role play in peer work consultations

Patient involvement is a prominent policy aim in modern health care. Today, mental health services employ peer workers (PWs) who have personal experiences with mental illness. Based on 22 interviews with PWs and 26 audio recordings of real-life consultations, we show how PWs talk about their personal experiences as professional qualifications. Furthermore, we demonstrate how in real-life encounters, PWs and patients convert personal experiences into a professional approach through an interactionist role play that balance PWs role as former patients and current professionals. Our analysis shows that PWs combine the personal pronoun 'I' (stressing that it is personal) with the indefinite pronoun 'one' (referring to generalised patient experiences) when they recount illness experiences. This convey that PWs engage with mental illness as both a personal and professional topic. In addition, the analysis shows that PWs (and patients) use professional clues to manifest PWs' positions as professionals. Overall, the article demonstrates that instead of focussing on authentic patient relationships, as previous research has done, it is beneficial to investigate peer work from a symbolic interactionist approach revealing how PWs and patients skilfully manoeuvre the contradictions embedded in the PWs' dual role as former patients and current professionals.

Doing peer work in mental health services: Unpacking different enactments of lived experiences

Mental health services are increasingly employing peer workers (PWs), individuals who have lived experiences with mental health problems, to support patients and be part of mental health care teams. While the employment of PWs continues to increase, little is known about how the function unfolds in practice. This paper explores the broader context in which the PWs navigate and the concrete outcomes and everyday issues that exist at the individual level. Methodologically, the paper draws on 22 interviews with PWs employed in the mental health services in Denmark. Theoretically, it combines Lipsky's (1980) theory on street-level bureaucrats with sociological discussions concerning the lay-expert divide. The analysis shows that PWs experience both role ambiguity and goal uncertainty and that they use substantial discretion in determining the nature, amount and quality of their peer practices. This - combined with the PWs' diverse lived experiences - calls for a heterogeneous understanding of peer work and therefore the analysis presents three categories of peer workers: PWs as (1) a representative of patients' lifeworld, (2) an interdisciplinary professional and (3) an 'expert by experience'. These categories display PWs different enactments of their lived experiences and reveal ambiguities tied to the lay-expert divide.

Experiential knowledge in mental health services: Analysing the enactment of expertise in peer support

The shift towards recovery-oriented mental health care has led to the extensive growth of peer support in contemporary service delivery. When enacting peer support, peer workers (PWs) use their lived experiences of mental illness to provide support to individuals experiencing mental health difficulties. While PWs are increasingly an integrated part of mental health services, the way in which peer support unfolds in everyday practices remains understudied. Drawing on ethnographic fieldwork from Danish mental health centres, this paper investigates how peer workers and users enact experiential knowledge and expertise to support one another. Theoretically, this paper draws on a micro-sociological approach that comprehends expertise as an interactional accomplishment enacted within institutional arrangements. First, the analysis shows how PWs and users develop affective relations based on shared illness experiences that enable the enactment of expertise. Second, it demonstrates how PWs and users engage in these relations by exchanging sympathy and knowledge according to different situational demands. Third, it shows how experiences of relational limitations make service users contest the value of experiential knowledge and PWs' position as valid experts. Centrally, this paper contributes to a general discussion of expertise and the implications of bringing lived experiences into mental health services.

Characterizing suicide-related self-disclosure by peer specialists: a qualitative analysis of audio-recorded sessions

Objective

We characterized peer support specialists' self-disclosures related to suicide and recipient responses to inform services for high-risk individuals that may include peer support.

Method

We used an inductive approach and thematic analysis to identify themes from audio recordings of initial sessions between peer support specialists trained in suicide-related self-disclosure and 10 study participants who were admitted to inpatient psychiatry units with suicidal ideation or a suicide attempt.

Results

The first theme, "I've been suicidal, but those details are not important", reflects that peers mentioned suicide-related aspects of their histories briefly, often as part of introductions, without participants responding specifically to those aspects. The second theme, "Being suicidal is one of the challenges I've faced", reflects that in more detailed disclosures by peer specialists and in participant responses, suicide is a part of the mental health challenges and life stressors discussed, not the focus. The third theme "Let's focus on my recovery and what I've learned" reflects that peers steered their self-disclosures away from suicide and towards what was helpful in their recovery.

Conclusions

Suicide-related self-disclosures embedded within peer specialists' introduction or overall recovery narrative convey a shared experience while focusing conversation on mental health challenges other than suicide.

Caregiver Support in Mental Health Recovery: A Critical Realist Qualitative Research

Support from caregivers is an important element of mental health recovery. However, the mechanisms by which social support influences the recovery of persons with depressive, anxiety, or bipolar disorders are less understood. In this study, we describe the social support mechanisms that influence mental health recovery. A cross-sectional qualitative study was undertaken in Québec (Canada) with 15 persons in recovery and 15 caregivers-those having played the most significant role in their recovery. A deductive thematic analysis allowed for the identification and description of different mechanisms through a triangulation of perspectives from different actors. Regarding classic social support functions, several of the support mechanisms for mental health recovery were identified (emotional support, companionship, instrumental support, and validation). However, informational support was not mentioned. New mechanisms were also identified: presence, communication, and influence. Social support mechanisms evoke a model containing a hierarchy as well as links among them.

Strategies Used to Support Peer Provision in Mental Health: A Scoping Review

The employment of peer providers (people who draw on their lived experience of mental health challenges) has grown in conjunction with the increased acceptance of recovery as a key principle in mental health policy and practice. Barriers to the integration of peer providers in mental health services have been well documented. This review addresses an under-explored area by consolidating strategies undertaken by mental health organizations for the successful implementation of peer provision. A scoping review was chosen to facilitate the rapid summary and dissemination of research findings that are relevant to policymakers and practitioners. Peer-reviewed articles and grey literature were sourced from three databases, key peer support websites and a hand search of the included studies. Following screening, data were extracted from 28 studies: 25 qualitative and three mixed methods studies. The data were analyzed using thematic analysis and organized into themes. Four themes emerged from the data. Championing of peer provision initiatives by organizational leadership is central to the success and sustainability of peer provision. Leadership undergirds three strategies that were discussed: organizational preparation, recruitment, training and induction, and support and development. When peer provision is championed by organizational leadership, measures can be undertaken to prepare the organization for peer provision; recruit, train and induce peer providers successfully into the organization; and support peer providers on the job.

Peer support for people with severe mental illness versus usual care in high-, middle- and low-income countries: study protocol for a pragmatic, multicentre, randomised controlled trial (UPSIDES-RCT)

BACKGROUND

Peer support is an established intervention involving a person recovering from mental illness supporting others with mental illness. Peer support is an under-used resource in global mental health. Building upon comprehensive formative research, this study will rigorously evaluate the impact of peer support at multiple levels, including service user outcomes (psychosocial and clinical), peer support worker outcomes (work role and empowerment), service outcomes (cost-effectiveness and return on investment), and implementation outcomes (adoption, sustainability and organisational change).

METHODS

UPSIDES-RCT is a pragmatic, parallel-group, multicentre, randomised controlled trial assessing the effectiveness of using peer support in developing empowering mental health services (UPSIDES) at four measurement points over 1 year (baseline, 4-, 8- and 12-month follow-up), with embedded process evaluation and cost-effectiveness analysis. Research will take place in a range of high-, middle- and low-income countries (Germany, UK, Israel, India, Uganda and Tanzania). The primary outcome is social inclusion of service users with severe mental illness (N = 558; N = 93 per site) at 8-month follow-up, measured with the Social Inclusion Scale. Secondary outcomes include empowerment (using the Empowerment Scale), hope (using the HOPE scale), recovery (using Stages of Recovery) and health and social functioning (using the Health of the Nations Outcome Scales). Mixed-methods process evaluation will investigate mediators and moderators of effect and the implementation experiences of four UPSIDES stakeholder groups (service users, peer support workers, mental health workers and policy makers). A cost-effectiveness analysis examining cost-utility and health budget impact will estimate the value for money of UPSIDES peer support.

DISCUSSION

The UPSIDES-RCT will explore the essential components necessary to create a peer support model in mental health care, while providing the evidence required to sustain and eventually scale-up the intervention in different cultural, organisational and resource settings. By actively involving and empowering service users, UPSIDES will move mental health systems toward a recovery orientation, emphasising user-centredness, community participation and the realisation of mental health as a human right.

TRIAL REGISTRATION

ISRCTN, ISRCTN26008944. Registered on 30 October 2019.

A Complexity Perspective on Narrative Identity Reconstruction in Mental Health Recovery

The issue of complex nonlinear change processes is one of the least understood aspects of recovery and one of the most difficult to apply in recovery-oriented health care. The purpose of this article is to explore the recovery stories of 17 mental health peer support workers to understand their narrative identity reconstruction in recovery using a complexity perspective. Using the Life Story Model of Identity (LSMI), a narrative thematic analysis of interviews suggests that self-mastery as part of personal agency is an important component of participants' narrative identity reconstruction. Self-mastery is particularly evident in redemptive story turning points (positive outcome follows negative experience). A complexity perspective suggests that participants realized their adaptive capacity in relation to self-mastery as part of recovery and that its use at story turning points critically influenced their recovery journey. Further exploring self-mastery as adaptive growth in narrative identity reconstruction appears to be a fruitful research direction.

Struggling With Reciprocity and Compassion: Mentoring Pregnant and Parenting Mothers Experiencing Vulnerability

Transitioning from pregnancy to parenthood is particularly challenging for women living with low income and experiencing social isolation, mental illness, addiction, and/or family violence. The purpose of this qualitative study was to evaluate one component of Welcome to Parenthood, a two-generation multiple intervention program including neuroscience-based parenting education, kin and non-kin mentorship, and an engagement tool (baby kit). From late pregnancy to 2 months postpartum, mentors kept a journal regarding their experiences of mentoring mothers experiencing vulnerability. We engaged in a modified constructivist grounded theory to explore hand-written text from the journals. The core category, Struggling with Reciprocity and Compassion, influenced processes of Becoming a Mentor. Mentoring mothers experiencing vulnerability was both challenging and rewarding, requiring an inordinate amount of physical, social, emotional, and economic resources. To foster maternal mental health and infant development, pregnant and parenting women experiencing vulnerability could benefit from long-term reciprocal and compassionate mentoring.