User and carer involvement in mental health services: from rhetoric to science

Training to enhance user and carer involvement in mental health-care planning: the EQUIP research programme including a cluster RCT

Background

Service users and carers using mental health services want more involvement in their care and the aim of this research programme was to enhance service user and carer involvement in care planning in mental health services.

Objectives

Co-develop and co-deliver a training intervention for health professionals in community mental health teams, which aimed to enhance service user and carer involvement in care planning. Develop a patient-reported outcome measure of service user involvement in care planning, design an audit tool and assess individual preferences for key aspects of care planning involvement. Evaluate the clinical effectiveness and the cost-effectiveness of the training. Understand the barriers to and facilitators of implementing service user- and carer-involved care planning. Disseminate resources to stakeholders.

Methods

A systematic review, focus groups and interviews with service users/carers/health professionals informed the training and determined the priorities underpinning involvement in care planning. Data from focus groups and interviews were combined and analysed using framework analysis. The results of the systematic review, focus groups/interviews and a review of the training interventions were synthesised to develop the final training intervention. To develop and validate the patient-reported outcome measure, items were generated from focus groups and interviews, and a psychometric analysis was conducted. Patient-reported outcome measure items and a three-round consensus exercise were used to develop an audit tool, and a stated preference survey was undertaken to assess individual preferences for key aspects of care planning. The clinical effectiveness and cost-effectiveness of the training were evaluated using a pragmatic cluster trial with cohort and cross-sectional samples. A nested longitudinal qualitative process evaluation using multiple methods, including semistructured interviews with key informants involved locally and nationally in mental health policy, practice and research, was undertaken. A mapping exercise was used to determine current practice, and semistructured interviews were undertaken with service users and mental health professionals from both the usual-care and the intervention arms of the trial at three time points (i.e. baseline and 6 months and 12 months post intervention).

Results

The results from focus groups (n = 56) and interviews (n = 74) highlighted a need to deliver training to increase the quality of care planning and a training intervention was developed. We recruited 402 participants to develop the final 14-item patient-reported outcome measure and a six-item audit tool. We recruited 232 participants for the stated preference survey and found that preferences were strongest for the attribute ‘my preferences for care are included in the care plan’. The training was delivered to 304 care co-ordinators working in community mental health teams across 10 NHS trusts. The cluster trial and cross-sectional survey recruited 1286 service users and 90 carers, and the primary outcome was the Health Care Climate Questionnaire. Training was positively evaluated. The results showed no statistically significant difference on the primary outcome (the Health Care Climate Questionnaire) (adjusted mean difference –0.064, 95% confidence interval –0.343 to 0.215; p = 0.654) or secondary outcomes at the 6-month follow-up. Overall, the training intervention was associated with a net saving of –£54.00 (95% confidence interval –£193.00 to £84.00), with a net quality-adjusted life-year loss of –0.014 (95% confidence interval –0.034 to 0.005). The longitudinal process evaluation recruited 54 service users, professionals and carers, finding a failure of training to become embedded in routine care.

Limitations

Our pragmatic study was designed to improve service user and care involvement in care planning among routine community mental health services. We intervened in 18 sites with > 300 care co-ordinators. However, our volunteer sites may not be fully representative of the wider population, and we lacked data with which to compare our participants with the eligible population.

Conclusions

We co-developed and co-delivered a training intervention and developed a unidimensional measure of service user and carer involvement in care planning and an audit tool. Despite a high level of satisfaction with the training, no significant effect was found; therefore, the intervention was ineffective. There was a failure of training to become embedded and normalised because of a lack of organisational readiness to accept change. Working with NHS trusts in our ‘Willing Adopters’ programme with enhanced organisational buy-in yielded some promising results.

Future work

Research should focus on developing and evaluating new organisational initiatives in addition to training health-care professionals to address contextual barriers to service and carer involvement in care planning, and explore co-designing and delivering new ways of enhancing service users’ and carers’ capabilities to engage in care planning.

Trial registration

Current Controlled Trials ISRCTN16488358.

Funding

This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 7, No. 9. See the NIHR Journals Library website for further project information.

Where is the family voice? Examining the relational dimensions of the family- healthcare professional and its perceived impact on patient care outcomes in mental health and addictions

Background

We explored the relationship between family members and healthcare professionals (HCPs), specifically how family members can influence the course and outcome of patient care for youth. Exploring this under-researched area provided an opportunity to understand the tripartite relationship between the family, the youth experiencing mental health problems or substance use concerns and their HCP.

Methods

A qualitative research design was used to gain a full understanding of how family members experience relationships with HCPs. We interviewed 21 family members using semi-structure questions to explore the type of relationships formed between HCPs and family members throughout a patient’s course of care, the family member’s perceived role in the care of their youth accessing mental health or addiction services and the family member’s awareness of formalized structures (i.e., hospital rules, policies) and resources that support family involvement.

Results

Within a relationship-centred framework, four themes, with various sub-themes emerged from the interviews: 1) The family member–HCP relationship regarding creating a positive impression, being an extension of the patient and the discovery of “pink flags”; 2) The family member–youth–HCP relationship regarding the receptivity of youth to family involvement and a youth’s individual right to privacy; 3)The family member’s relationship to self with regard to the situation being a family illness; and 4) The family member’s relationship with friends, family and peers regarding the feelings of loneliness, stigma and shame and the lack of understanding about mental health problems and substance use.

Conclusions

Our study provided in-depth information about the importance of family involvement in the care and health outcomes of youth who are accessing mental health and addiction services. Family members experienced and conceptualized their relationships with HCPs, their youth, themselves and their friends and peers as active interactions that influenced the course and outcomes of care. Future studies are needed to collect the multiple perspectives of youth and HCPs alongside with the family perspectives.

A voice for the patients: Evaluation of the implementation of a strategic organizational committee for patient engagement in mental health

OBJECTIVE

There is a need for structure to achieve functional patient engagement within mental healthcare organizations, and for clarification on how to proceed on a strategic level. The aim of this paper is to shed light on the implementation of a strategic organizational structure for patient engagement in mental health by examining why and how to implement a structure, the organizational and environmental factors that facilitate or limit the process, and the perceived consequences of the implementation.

METHOD

This paper evaluates the implementation of a strategic committee for patient engagement in a mental healthcare organization in Montreal (Quebec, Canada). The research was designed as a qualitative single case study using a deductive approach by means of a conceptual framework. Data sources consisted in ten semi-structured interviews, three focus groups, and organizational documents.

RESULTS

The strategic committee for patient engagement was implemented as a means to formalize patient partner participation, following the introduction of a vision of full citizenship. Important aspects of its implementation included its composition and role, the elaboration of a framework for patient partner participation, and finally, ongoing application and evaluation of the framework. Several facilitating factors were identified, including executive management support, leadership, and a vision behind the participation. Limiting factors mainly consisted of resistance towards patient participation and the existence of stigma. Consequences included increased and improved patient engagement, as well as reduced stigma within the organization.

CONCLUSION

This study shows that the implementation of a strategic organizational structure for patient engagement is comprehensive. It further shows the importance of a vision and an articulate leadership involving several actors. Further research is needed regarding the impact of this type of strategic structure on a clinical level.

Evaluating the effectiveness of a culturally adapted behavioral family psycho-educational program for Egyptian patients with schizophrenia

Although a growing body of evidence supports the effectiveness of behavioral family therapies for patients with schizophrenia, few studies have been carried out on the effectiveness of such programs for Egyptian patients. The current study translated and culturally adapted the Behavioral Family Psycho-Education Program (BFPEP) and conducted a preliminary efficacy evaluation for outpatients suffering from schizophrenia. Thirty patients received 14 sessions of culturally adapted Program (CA-BFPEP) and 30 received treatment as usual; all were followed up for 6 months. Pre- and post-intervention assessment included primary outcome measures that assessed the clinical, social, quality of life and attitude towards medications. The CA-BFPEP group demonstrated significant treatment effects as they had greater reductions in psychotic symptoms (PANSS), improvement of social function (SFQ), quality of life (QoL), and attitude towards medications (DAI), compared to patients in the control group. These results demonstrate the feasibility of implementing family therapy interventions in different cultural settings with relatively minor modifications. These promising findings invite further efforts to maximize the benefits of family therapy interventions internationally and to encourage mental health policy makers to integrate this mode of therapy in routine care management plans for patients with schizophrenia.

Working with people with personality disorder: utilising service users' views

Aims and Method

To ascertain the views of people with personality disorder on their clinical interactions with professionals, to identify potential solutions to problematic interactions and to compile guidelines on how professionals could improve their interactions with these service users. Qualitative methodology was employed, comprising a modified nominal group technique with two iterative groups and ranking by importance the issues and themes raised.

Results

There were 13 service users from three separate personality disorder services who actively participated in a group discussion and iterative process. Collectively they indicated considerable areas of deficiency in the quality of their interaction and communication with professionals. These deficits were defined clearly enough to allow the construction of guidelines aimed at preventing or remedying such deficiencies.

Conclusions

The contribution of those people with personality disorder who took part in this study was sufficiently thoughtful to allow the development of guidelines that might help staff improve their interactions with such service users. From these guidelines, further training tools are being developed, which will be evaluated in the future. However, because not all those approached chose to participate, the views expressed might not be representative of this group as a whole.

Is it time to abandon care planning in mental health services? A qualitative study exploring the views of professionals, service users and carers

BACKGROUND

It has been established that mental health-care planning does not adequately respond to the needs of those accessing services. Understanding the reasons for this and identifying whose needs care plans serve requires an exploration of the perspectives of service users, carers and professionals within the wider organizational context.

OBJECTIVE

To explore the current operationalization of care planning and perceptions of its function within mental health services from the perspectives of multiple stakeholders.

SETTINGS AND PARTICIPANTS

Participants included 21 mental health professionals, 29 service users and 4 carers from seven Mental Health Trusts in England. All participants had experience of care planning processes within secondary mental health-care services.

METHODS

Fifty-four semi-structured interviews were conducted with participants and analysed utilizing a qualitative framework approach.

FINDINGS

Care plans and care planning were characterized by a failure to meet the complexity of mental health needs, and care planning processes were seen to prioritize organizational agendas and risk prevention which distanced care planning from the everyday lives of service users.

DISCUSSION AND CONCLUSIONS

Care planning is recognized, embedded and well established in the practices of mental health professionals and service users. However, it is considered too superficial and mainly irrelevant to users for managing mental health in their everyday lives. Those responsible for the planning and delivery of mental health services should consider ways to increase the relevance of care planning to the everyday lives of service users including separating risk from holistic needs assessment, using support aids and utilizing a peer workforce in this regard.

Protocol for a qualitative study exploring perspectives on the INternational CLassification of Diseases (11th revision); Using lived experience to improve mental health Diagnosis in NHS England: INCLUDE study

INTRODUCTION

Developed in dialogue with WHO, this research aims to incorporate lived experience and views in the refinement of the International Classification of Diseases Mental and Behavioural Disorders 11th Revision (ICD-11). The validity and clinical utility of psychiatric diagnostic systems has been questioned by both service users and clinicians, as not all aspects reflect their lived experience or are user friendly. This is critical as evidence suggests that diagnosis can impact service user experience, identity, service use and outcomes. Feedback and recommendations from service users and clinicians should help minimise the potential for unintended negative consequences and improve the accuracy, validity and clinical utility of the ICD-11.

METHODS AND ANALYSIS

The name INCLUDE reflects the value of expertise by experience as all aspects of the proposed study are co-produced. Feedback on the planned criteria for the ICD-11 will be sought through focus groups with service users and clinicians. The data from these groups will be coded and inductively analysed using a thematic analysis approach. Findings from this will be used to form the basis of co-produced recommendations for the ICD-11. Two service user focus groups will be conducted for each of these diagnoses: Personality Disorder, Bipolar I Disorder, Schizophrenia, Depressive Disorder and Generalised Anxiety Disorder. There will be four focus groups with clinicians (psychiatrists, general practitioners and clinical psychologists).

ETHICS AND DISSEMINATION

This study has received ethical approval from the Coventry and Warwickshire HRA Research Ethics Committee (16/WM/0479). The output for the project will be recommendations that reflect the views and experiences of experts by experience (service users and clinicians). The findings will be disseminated via conferences and peer-reviewed publications. As the ICD is an international tool, the aim is for the methodology to be internationally disseminated for replication by other groups.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov: NCT03131505.

Consumer and carer perspectives in the development of a mental health research, treatment and teaching facility: A thematic analysis

WHAT IS KNOWN ON THE SUBJECT?: Around the world, recovery has become a focus in mental health policy. The participation of people accessing mental health services (consumers) and carers of such individuals in decision-making related to services forms part of this recovery orientation and studies suggest positive outcomes following such participation. However, little is known about consumer and carer desires at the earliest stages of development of new services. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: Consumers and carers desire changes to how mental health services are provided. Many factors affect consumer and carer experiences, including language use, physical design of spaces, accessibility, consideration of individual needs, practical help and how well care is continued from hospital to community settings. Carers may feel sidelined in treatment and be distressed as a result. They wish to be respected and involved in recovery. Consumers and carers wish for focus on broader health, with care taken to address physical health, psychological needs, social needs and treatment of the whole person rather than just an illness. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Consumers and carers desire partnership with professionals in recovery. Tokenistic participation should be avoided. Flexibility in how services are provided and less formality may help engage consumers and carers. Specifically, professionals may help by linking consumers and carers to services that address practical needs. Professionals should communicate with carers to draw on their expertise about the individual accessing the mental health service and help carers understand how they can assist the individual's recovery.

ABSTRACT

Introduction Recovery-oriented mental health policies recognize consumer and carer participation in service decision-making as essential, but little is known about the views of these individuals in the earliest stages of service development. Aim This study sought consumer and carer perspectives addressing the establishment of a mental health research, treatment and teaching facility in their region. Methods Two 2-hr focus groups were conducted, with separate groups held for mental health consumers (n = 9) and carers (n = 9), respectively. Discussions pertained to mental health literacy, gaps in current services, desires for an ideal facility (in terms of physical design and services offered) and what would help in recovery. Results Inductive thematic analysis was used to generate three themes: care outside of consultations, carer involvement in recovery and holistic approaches to mental health care. Consumers desired a facility that could cater to individual needs. Carers felt excluded in recovery and unable to provide effective support. Both groups preferred holistic approaches to mental health, expressing ambivalence towards medication and hospitalization. Discussion Consumers and carers have many needs that conventional practices may not meet. Implications for practice They have clear desires for equal partnership in recovery and for transformation of conventional treatment methods.

Improving mental health in later life: the role of service user involvement

Purpose

The purpose of this paper is to describe service user involvement, explain some of the key issues that define, affect or protect mental health in later life and show how involvement may contribute to better mental health in later life.

Design/methodology/approach

The paper reviews existing definitions of involvement and mental health in later life; provides a more detailed review of some examples of involvement at a range of levels and illustrates how these could have a positive impact on mental health.

Findings

Active involvement and engagement at all levels offers significant opportunities for older people to protect and improve their own mental health and the mental health of society as a whole.

Research limitations/implications

This research does not set out to promote any particular intervention or involvement technique. The examples given have been evaluated in a variety of ways.

Practical implications

Service user involvement should be considered as an important potential contributor to mental health in later life.

Social implications

The paper encourages people in later life to be considered as a community resource rather than a problem that needs to be solved.

Originality/value

This paper brings together existing research with a focus on the relationship between involvement and individual and collective mental health.

Psychosis seminars: an open forum for service users, carers and professionals

BACKGROUND

Psychosis seminars enable service users, their carers and mental health professionals to meet outside of a formal care setting, increase understanding of mental illness and help establish a dialogue.

AIMS

To explore feasibility of psychosis seminars in the UK and the experiences of participants.

METHOD

Seven meetings attended by 25 people were held over a 3-month period. An open-ended questionnaire was returned by ten participants. Responses were subjected to content analysis.

RESULTS

Benefits experienced were having an open forum for talking freely about mental health issues in a neutral space, learning from others about psychosis and hearing different views. Suggested adjustments were clarifying expectations of participants at the beginning, strengthening facilitation and increasing attendance.

CONCLUSIONS

Psychosis seminars may help to establish a dialogue among users, carers and professionals and seem feasible in the UK, although adjustment to delivery can help their implementation.

DECLARATION OF INTEREST

None.

COPYRIGHT AND USAGE

© The Royal College of Psychiatrists 2016. This is an open access article distributed under the terms of the Creative Commons Attribution (CC BY) license.

"Very much evolving": a qualitative study of the views of psychiatrists about peer support workers

BACKGROUND

Mental health services continue to develop service user involvement, including a growth in employment of peer support workers (PSWs). Despite the importance of the views and attitudes expressed by psychiatrists, this topic has not previously been studied.

AIMS

To gain insight into the views and attitudes psychiatrists have about PSWs.

METHODS

A qualitative study based on semi-structured interviews with 11 psychiatrists in the East of England.

RESULTS

Psychiatrists were broadly positive and supportive of PSWs. Interviewees not only could anticipate a range of possible benefits of employing PSWs, but also had concerns regarding their implementation and management. There was a lack of clarity and consistency between interviewees about what the exact role of a PSW might involve.

CONCLUSION

This study provides insights into how PSWs are perceived by psychiatrists. While broadly positive attitudes exist, the research highlights certain challenges, particularly role ambiguity.

More than just a bed: mental health service users' experiences of self-referral admission

BACKGROUND

Several community mental health centres and mental hospitals in Norway now allow users with a diagnosis of severe mental illness to self-refer for admission. This give a group of service users who are well-known to service providers the opportunity to refer themselves for short inpatient stays without contacting their doctor, a duty doctor or emergency department. Evidence on self-referral admissions is lacking.

AIM

To explore service users' experiences of having the opportunity to refer themselves for a short inpatient stay.

METHODS

Forty-two qualitative semi-structured interviews were undertaken between 2010 and 2014 in a group of 28 service users with serious mental illness and with or without substance abuse problems. All respondents had a contract which allowed them to self-refer for inpatient treatment. Systematic text condensation was applied in the analyses.

RESULTS

Self-referral inpatient admission is more than just a bed. It was perceived as a new, unconventional health service, which differed substantially from earlier experiences of inpatient care and was characterised by different values and treatment principles. The differences were related to the content, quality and organisation of treatment. Having the option to decide about admission for oneself and having access to services focusing on individual needs seem to enhance service users' confidence, both in the services they use and in their own ability to cope with everyday life.

CONCLUSIONS

Self-referral inpatient admission is a concrete example of how a user involvement policy can be implemented in mental health services. It is important to emphasise that the self-referral admission process described here is an offer in development and that we are awaiting findings from a larger RCT study. More evidence is needed to determine what aspects of the service are helpful to service users, the long-term effects, appropriateness and cost-effectiveness, and how the service can be integrated into the mental health system.

Patients' Needs for Care in Public Mental Health: Unity and Diversity of Self-Assessed Needs for Care

PURPOSE

Needs assessment is recognized to be a key element of mental health care. Patients tend to present heterogeneous profiles of needs. However, there is no consensus in previous research about how patients' needs are organized. This study investigates both general and specific dimensions of patients' needs for care.

METHODS

Patients' needs were assessed with ELADEB, an 18-domain self-report scale. The use of a self-assessment scale represents a unique way of obtaining patients' perceptions. A patient-centered psychiatric practice facilitates empowerment as it is based on the patients' personal motivations, needs, and wants. Four seventy-one patients' profiles were analyzed through exploratory factor analysis.

RESULTS

A four-factor bifactor model, including one general factor and three specific factors of needs, was most adequate. Specific factors were (a) "finances" and "administrative tasks"; (b) "transports," "public places," "self-care," "housework," and "food"; and (c) "family," "children," "intimate relationships," and "friendship."

CONCLUSION

As revealed by the general factor, patients expressing urgent needs in some domains are also more susceptible to report urgent needs in several other domains. This general factor relates to high versus low utilizers of public mental healthcare. Patients also present specific needs in life domains, which are organized in three dimensions: management, functional disabilities, and familial and interpersonal relationships. These dimensions relate to the different types of existing social support described in the literature.

Evaluation of patient involvement in a health technology assessment

OBJECTIVES

We sought to evaluate patient involvement (consultation and direct participation) in the assessment of alternative measures to restraint and seclusion among adults in short-term hospital wards (in psychiatry) and long-term care facilities for the elderly.

METHODS

We conducted individual semi-structured interviews with thirteen stakeholders: caregivers, healthcare managers, patient representatives, health technology assessment (HTA) unit members, researchers, and members of the local HTA scientific committee. Data were collected until saturation. We carried out content analysis of two HTA reports and four other documents that were produced in relation with this HTA. We also used field notes taken during formal meetings and informal discussions with stakeholders. We performed thematic analysis based on a framework for assessing patient involvement in HTA. We then triangulated data.

RESULTS

For the majority of interviewees, patient consultation enriched the content of the HTA report and its recommendations. This also made it possible to suggest other alternatives that could reduce the use of restraint and seclusion and helped confirm some views and comments from healthcare professionals consulted in this HTA. The direct participation of patient representatives enabled rephrasing of some findings so as to bring the patient perspective to the HTA report.

CONCLUSIONS

Patient consultation was seen as having directly influenced the content of the HTA report while direct participation made it possible to rephrase some findings. This is one of few studies to assess the impact of patient involvement in HTA and more such studies are needed to identify the best ways to improve the input of such involvement.

Challenges in measuring outcomes for caregivers of people with mental health problems

Patient-reported outcomes (PROs) are increasingly important in health care and mental health research. Furthermore, caregivers become partners in care for patients with mental disorders, and health workers are more attentive to the expectations and needs of caregivers. A number of outcomes for caregivers are measured and used in daily practice in order to promote actions to improve health care systems and progress in research on the impact of mental disorders on their caregivers. This paper proposes an inventory of the different outcomes and different measurement tools used to assess the impact of disorders, raising a number of methodological and conceptual issues that limit the relevance of measurement tools and complicate their use. Finally, we propose some recommendations promoting the development of relevant outcome measures for caregivers and their integration into current systems of care.

A scoping review of the literature on the involvement of service users in personality disorder services

BACKGROUND

Service user involvement is receiving increasing support from mental health policy makers, service planners and research commissioners. However, we lack a good understanding of the nature and extent to which service users are involved in personality disorder (PD) services and the effects of involvement in these services.

OBJECTIVES

To review and appraise published sources; increase understanding about service user involvement in PD services; and highlight knowledge gaps and related issues.

METHODS

A scoping review methodology was adopted. Data were 'charted' to illustrate the landscape of writings and views and a qualitative analysis synthesized the results in terms of key emergent themes.

RESULTS

Only a small amount of published work was identified with significant gaps in the literature. Effects were reported mostly in terms processes and emotional and practical benefits for service users. Emergent themes were wellness and health, recruitment and support for service users.

CONCLUSIONS

This scoping review uncovered a lack of published work despite service user involvement being a key strand of health policy. There is a need for outcomes-focused research regarding service user involvement. Successful user involvement in PD services requires attention to be focused on the context, recruitment, support and 'wellness' of service users.

Implementing family involvement in the treatment of patients with psychosis: a systematic review of facilitating and hindering factors

OBJECTIVE

To synthesise the evidence on implementing family involvement in the treatment of patients with psychosis with a focus on barriers, problems and facilitating factors.

DESIGN

Systematic review of studies evaluating the involvement of families in tripartite communication between health professionals, 'families' (or other unpaid carers) and adult patients, in a single-family context. A theoretical thematic analysis approach and thematic synthesis were used.

DATA SOURCES

A systematic electronic search was carried out in seven databases, using database-specific search strategies and controlled vocabulary. A secondary manual search of grey literature was performed as well as using forwards and backwards snowballing techniques.

RESULTS

A total of 43 studies were included. The majority featured qualitative data (n=42), focused solely on staff perspectives (n=32) and were carried out in the UK (n=23). Facilitating the training and ongoing supervision needs of staff are necessary but not sufficient conditions for a consistent involvement of families. Organisational cultures and paradigms can work to limit family involvement, and effective implementation appears to operate via a whole team coordinated effort at every level of the organisation, supported by strong leadership. Reservations about family involvement regarding power relations, fear of negative outcomes and the need for an exclusive patient-professional relationship may be explored and addressed through mutually trusting relationships.

CONCLUSIONS

Implementing family involvement carries additional challenges beyond those generally associated with translating research to practice. Implementation may require a cultural and organisational shift towards working with families. Family work can only be implemented if this is considered a shared goal of all members of a clinical team and/or mental health service, including the leaders of the organisation. This may imply a change in the ethos and practices of clinical teams, as well as the establishment of working routines that facilitate family involvement approaches.

The perceptions of the ward atmosphere in four Jordanian psychiatric hospitals from the perspective of patients' relatives

PURPOSE

To describes the perceptions of the ward atmosphere of psychiatric hospitals from the perspective of the relatives of people who were inpatients in those hospitals.

DESIGN AND METHODS

A nonexperimental descriptive survey was used. Data were collected using the Arabic version of Moos Ward Atmosphere Scale Ideal and Real forms.

FINDINGS

Data indicate that even though relatives of Jordanian mental health patients were generally positive about the ward atmosphere, they would like to see changes.

PRACTICE IMPLICATIONS

By describing their current and ideal treatment environments, participants have provided information that can guide interventions to change the ward atmosphere and thus help foster better patient treatment outcomes.

Patient involvement in mental health care: one size does not fit all

BACKGROUND

Involvement of mental health-care patients in the decision-making processes is considered to be an ethical requirement. Health-care systems worldwide are increasingly emphasizing the value of participatory approaches. There is, however, no consensus on the definition of patient involvement. The literature is particularly inconsistent and lacks clarity.

OBJECTIVE

The purpose of this article is to clarify the concept of patient involvement in mental health care (MHC), taking into account its multidimensional nature.

SEARCH STRATEGY

We searched the literature in online databases from January 1998 until August 2010 using synonyms of 'patient involvement', combined with the terms 'mental health(care)'.

DATA SYNTHESIS

Based on 45 different descriptions found in the literature, we constructed a definition of patient involvement and we drew up a model identifying its determinants and outcomes.

RESULTS

We propose a comprehensive model of patient involvement to be used in MHC. This model can serve as a guide for policy makers and field workers to shape policies to stimulate involvement.

DISCUSSION AND CONCLUSIONS

There are three main problems in the literature concerning patient involvement. First, there is a proliferation of conceptualizations of the topic, leading to conceptual vagueness. Furthermore, there is a lack of quantitative data, and some aspects of involvement remain underexposed, such as the involvement of specific target groups and practical ways to shape the involvement processes. Involvement processes should be tailored to the specific target group and context.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

A critical analysis of user satisfaction surveys in addiction services: opioid maintenance treatment as a representative case study

BACKGROUND

Satisfaction with services represents a key component of the user's perspective, and user satisfaction surveys are the most commonly used approach to evaluate the aforementioned perspective. The aim of this discursive paper is to provide a critical overview of user satisfaction surveys in addiction treatment and harm reduction services, with a particular focus on opioid maintenance treatment as a representative case.

METHODS

We carried out a selective critical review and analysis of the literature on user satisfaction surveys in addiction treatment and harm reduction services.

RESULTS

Most studies that have reported results of satisfaction surveys have found that the great majority of users (virtually all, in many cases) are highly satisfied with the services received. However, when these results are compared to the findings of studies that use different methodologies to explore the patient's perspective, the results are not as consistent as might be expected. It is not uncommon to find that "highly satisfied" patients report significant problems when mixed-methods studies are conducted. To understand this apparent contradiction, we explored two distinct (though not mutually exclusive) lines of reasoning, one of which concerns conceptual aspects and the other, methodological questions.

CONCLUSION

User satisfaction surveys, as currently designed and carried out in addiction treatment and harm reduction services, do not significantly help to improve service quality. Therefore, most of the enthusiasm and naiveté with which satisfaction surveys are currently performed and interpreted - and rarely acted on in the case of nonoptimal results - should be avoided. A truly participatory approach to program evaluation is urgently needed to reshape and transform patient satisfaction surveys.

Service user and family carer involvement in mental health care: divergent views

This study assessed differences between service users', family carers' and mental healthcare providers' perceptions on service user and family carer involvement in mental healthcare. We conducted questionnaires in care networks for persons with serious and persistent mental illness, among 111 service users, 73 family carers and 216 mental healthcare providers. Many aspects of service user and family carer involvement are achieved to satisfactory levels while other aspects are scarcely realized. Service users and mental healthcare providers perceive family carer involvement as less important and realized than service user involvement. Family carers hold more favorable views on the importance and realization of involvement than do mental healthcare providers. The implementation of stakeholders' involvement in healthcare is ongoing. Notwithstanding great efforts, service users' and family carers' involvement preferences are not yet fully considered. Developing procedures, training and monitoring cycles regarding involvement may enhance this situation.

Co-producing addiction aftercare

Purpose

– The purpose of this paper is to describe the development and delivery of an aftercare programme called Learning To Live Again, which was co-produced between service users and clinic staff.

Design/methodology/approach

– In total, 37 semi-structured interviews were conducted with 29 project stakeholders who were service users, mentors, university and clinical staff. The data were transcribed and analysed using thematic analysis.

Findings

– Four overarching themes were identified in the analysis of interview data as characterising the process of co-producing an aftercare programme. These were: achieving common ground, roles and responsibilities, the activities programme and the road to recovery. Interdependence of service users and clinicians was given strong emphasis.

Practical implications

– A number of challenges arise in co-producing an aftercare programme which is largely service user led and adds to the local recovery capital. The benefits of co-producing aftercare outweigh the difficulties and the programme can be set up within existing resources. Given the study's focus on the process of setting up and maintaining an aftercare programme, no attempt was made to evaluate the improvement in outcomes or cost-effectiveness.

Originality/value

– Many peer-mentor-led aftercare programmes have been set up and this paper describes stakeholders’ thoughts about the challenges and benefits of co-producing an aftercare programme.

Is perceived patient involvement in mental health care associated with satisfaction and empowerment?

BACKGROUND

Patients increasingly assume active roles in their mental health care. While there is a growing interest in patient involvement and patient-reported outcomes, there is insufficient research on the outcomes of patient involvement.

OBJECTIVE

The research questions in this study are as follows: 'To what extent is perceived patient involvement associated with satisfaction and empowerment?'; 'What is the nature of the relationship between satisfaction and empowerment?'; and 'To what extent are background variables associated with satisfaction and empowerment?'. We assumed that a higher degree of patient involvement is associated with higher satisfaction and empowerment scores and that satisfaction and empowerment are positively associated.

DESIGN, SETTING AND PARTICIPANTS

Data were gathered using surveys of 111 patients of 36 multidisciplinary care networks for persons with serious and persistent mental illness.

MAIN VARIABLES STUDIED AND MAIN OUTCOME MEASURES

Demographic characteristics, patient involvement and satisfaction were measured using a new questionnaire. Empowerment was assessed using the Dutch Empowerment Scale. Descriptive, univariate (Pearson's r and independent-samples t-tests), multivariate (hierarchical forced entry regression) and mixed-model analyses were conducted.

RESULTS

The hypotheses of positive associations between patient involvement, satisfaction and empowerment are confirmed. The demographics are not significantly related to satisfaction or empowerment, except for gender. Men reported higher empowerment scores than did women.

DISCUSSION AND CONCLUSIONS

Making patient involvement a reality is more than just an ethical imperative. It provides an opportunity to enhance patient-reported outcomes such as satisfaction and empowerment. Future research should focus on the nature of the association between satisfaction and empowerment.

Patient and carer participation in old age psychiatry in England. Part I: a systemic perspective of the historical and policy context

BACKGROUND

Patient and carer participation in old age psychiatry is less developed than in other areas of mental health. What can we learn from the historical context about increasing participation and how can it be conceptualized?

METHODS

The historical and policy context of patient and carer participation in the National Health Service is reviewed and related to the development of old age psychiatry in England and the parallel development of the mental health user movement.

RESULTS

Systemic theory is offered as a way of understanding how partnership between healthcare professionals, patients and carers might lead to service evolution by bringing a range of perspectives together in order to co-construct a mutually influenced outcome. It is further suggested that this might empower not only patients and carers but also healthcare staff at a time when they are under increasing pressures.

CONCLUSIONS

Old age psychiatry patients and carers struggle to be heard but have much to offer to services in partnership with healthcare professionals as partners and allies in service development.

Systematic review of the role of service users as researchers in mental health studies

Aims – Service user involvement in mental health service development and research is becoming more common in countries like the UK. USA and Canada. This systematic review of the international scientific literature has been carried out to assess the stage of development of mental health service users involvement in research. Method – Systematic review of any research project actively involving service users in any part of the research process. Results – Thirty-five studies met the inclusion and exclusion criteria and were included in the systematic review. Nine studies used quantitative techniques, 24 used qualitative techniques and two studies used both quantitative and qualitative techniques. While three studies were user-led, in three other studies the users were simply consulted but did not have any active role in the research. The remaining 29 studies were based on a collaboration between service users and professional researchers. Conclusions – The involvement of mental health service users in the research process is feasible both in quantitative and qualitative research studies. The involvement of service users in research has a number of benefits; such research requires more accurate planning and more time than the traditional research.

Declaration of Interest: none.

Partnerships for better mental health worldwide: WPA recommendations on best practices in working with service users and family carers

WPA President M. Maj established the Task Force on Best Practice in Working with Service Users and Carers in 2008, chaired by H. Herrman. The Task Force had the remit to create recommendations for the international mental health community on how to develop successful partnership working. The work began with a review of literature on service user and carer involvement and partnership. This set out a range of considerations for good practice, including choice of appropriate terminology, clarifying the partnership process and identifying and reducing barriers to partnership working. Based on the literature review and on the shared knowledge in the Task Force, a set of ten recommendations for good practice was developed. These recommendations were the basis for a worldwide consultation of stakeholders with expertise as service users, families and carers, and the WPA Board and Council. The results showed a strong consensus across the international mental health community on the ten recommendations, with the strongest agreement coming from service users and carers. This general consensus gives a basis for Task Force plans to seek support for activities to promote shared work worldwide to identify best practice examples and create a resource to assist others to begin successful collaboration.

Description and evaluation of a serious game intervention to engage low secure service users with serious mental illness in the design and refurbishment of their environment

Service user involvement in all levels of healthcare provision is the expectation of UK government policy. Involvement should not only include participation in the planning and delivery of health care but also the exercise of choice and opinions about that care. In practice, however, service user engagement is most often tokenistic, involving post hoc consultation over plans already committed to by services. This paper explores an Occupational Therapy-led initiative to use the Serious Game format to engage low secure service users with serious mental illness in the design, layout and refurbishment of their unit. Among other things how medication was to be dispensed on the new unit was explored by this game and led to significant replanning in response to service user involvement. The game format was found to be a useful tool in facilitating communication between professionals and a traditionally marginalized and powerless client group. It enabled service users to have a voice, it provided a format for that voice to be heard and made possible service-led change in the planning process.

Service-user involvement in forensic mental health care research: areas to consider when developing a collaborative study

BACKGROUND

Although service-users are increasingly involved in the conduct of research in mental health settings, involvement in forensic mental health settings is limited.

AIMS

 This paper looks at the factors perceived by professionals and service-users as important for developing collaborative research in forensic mental health settings.

METHOD

Following a collaborative research project undertaken in three forensic mental health units, the researchers involved in the project (professionals and service-users) reviewed factors perceived as important for developing service-user research in secure settings.

RESULTS

 Three broad themes were identified. The main issues considered within these themes were detailed.

CONCLUSIONS

 Service-users in forensic mental health settings are able to have full involvement in research.

'What difference does it make?' Finding evidence of the impact of mental health service user researchers on research into the experiences of detained psychiatric patients

BACKGROUND

Interest in the involvement of members of the public in health services research is increasingly focussed on evaluation of the impact of involvement on the research process and the production of knowledge about health. Service user involvement in mental health research is well-established, yet empirical studies into the impact of involvement are lacking.

OBJECTIVE

To investigate the potential to provide empirical evidence of the impact of service user researchers (SURs) on the research process.

DESIGN

The study uses a range of secondary analyses of interview transcripts from a qualitative study of the experiences of psychiatric patients detained under the Mental Health Act (1983) to compare the way in which SURs and conventional university researchers (URs) conduct and analyse qualitative interviews.

RESULTS

Analyses indicated some differences in the ways in which service user- and conventional URs conducted qualitative interviews. SURs were much more likely to code (analyse) interview transcripts in terms of interviewees' experiences and feelings, while conventional URs coded the same transcripts largely in terms of processes and procedures related to detention. The limitations of a secondary analysis based on small numbers of researchers are identified and discussed.

CONCLUSIONS

The study demonstrates the potential to develop a methodologically robust approach to evaluate empirically the impact of SURs on research process and findings, and is indicative of the potential benefits of collaborative research for informing evidence-based practice in mental health services.

Perceived Improvements in Service User Involvement in Two Clinical Psychology Training Courses

In line with current developments in mental health training, the doctoral courses in clinical psychology at two UK universities, Canterbury Christ Church and Surrey, have been working together to increase service user and carer involvement. A questionnaire was constructed and sent out at two time-points, one year apart, to examine staff and trainee ratings of service user and carer involvement, the friendliness of the course towards service user and carer experiences, and barriers and opportunities in relation to involvement. Initial validation work on the questionnaire is briefly presented, along with the final questionnaire subscales and items used. There were eight subscales, of which seven had reasonable internal consistency. Response rates from staff and trainee samples on each occasion ranged between 35% and 48%. The number of trainees responding to both surveys was 44, and staff 81. Ratings of service user and carer involvement improved significantly between the two time-points. However, there was no overall change in ratings of courses' friendliness towards service user and carer experiences, or of barriers and opportunities in relation to service user involvement. Trainees rated barriers to involvement lower than did staff at both times. The questionnaire may be useful for other courses in assessing staff and trainee perceptions of service user and carer involvement.

The association between substance use and the needs of patients with psychiatric disorder, levels of anxiety, and caregiving burden

The influence of substance use on patient's needs and caregiving consequences has received insufficient research attention. We sought to determine whether patients with comorbid substance use have higher levels of need, anxiety, depression, and caregiving consequences than those of patients who do not use substances. A total of 520 patients participated, and those who used substances (n = 216) reported higher levels of unmet needs, anxiety, and caregiving consequences than did patients who did not use substances. Carers of patients who used substances also reported higher anxiety and more caregiving consequences. Very few patients were actively involved in treatment programs to reduce their substance use.

Consumer-clinician co-taught training about borderline personality disorder

OBJECTIVE

The aim of this paper is to provide further outcome data on a novel consumer-clinician co-taught borderline personality disorder training program.

METHOD

Participants (n=216) who attended consumer-clinician co-taught borderline personality disorder training had their ratings of the training compared to ratings of participants who attended the previous clinician-only borderline personality disorder training.

RESULTS

Mean training ratings of the consumer-clinician co-taught borderline personality disorder trainings were 37 percentile points higher (77th vs 40th percentile) than the ratings of the previous clinician-only borderline personality disorder training, which already had evidence of effectiveness.

CONCLUSION

Data confirm preliminary findings that adding a consumer-presenter to training adds considerable value.

Mental health professionals' attitudes towards consumer participation in inpatient units

Consumer participation has been a major focus in mental health services in recent years, but the attitudes of mental health professionals towards this initiative remain variable. The purpose of this study was to describe mental health professionals' attitudes towards mental health consumer participation in inpatient psychiatric units. The Consumer Participation and Consultant Questionnaire was used with a non-probability sample of 47 mental health professionals from two adult inpatient psychiatric units situated in a large Australian public general hospital. Ethics approval was obtained from a university and a hospital ethics committee. Data were analysed using SPSS, Version 12. Overall, respondents had favourable attitudes towards consumer participation in management, care and treatment, and mental health planning. They were less supportive about matters that directly or indirectly related to their spheres of responsibility. The type of unit that the respondents worked in was not a factor in their beliefs about consumer participation. Recommendations are made about the development of guidelines for consumer participation in inpatient units, the educational preparation of mental health clinicians, and the need for mental health professionals to reflect on, and discuss their own beliefs and practices about, consumer participation.

Consumer-clinician co-taught borderline personality disorder training: a pilot evaluation

This paper describes a consumer-clinician co-taught borderline personality disorder training programme for clinicians, of whom the largest group were nurses, working in mental health and substance use fields. A pilot evaluation of 73 participants attending the training rated the training as superior to evaluations of an earlier clinician-only-taught training. This study of a novel co-taught training programme found that the consumer input added substantial value. Findings indicate that consumer input into education programmes can make a significant positive contribution to the delivery of mental health services training with likely impacts on mental health service delivery. The potential importance of the findings warrants a comprehensive multicentre study. Confirming the findings would have implications for future borderline personality disorder training programmes.

Patients' experiences of recurrent depression

This study explores the lived experiences of individuals who are suffering from recurrent depression. Open interviews were conducted in Sweden with ten participants aged 19-67. Guided by the phenomenological method of Giorgi, data were analyzed within a Reflective Lifeworld Approach. The findings revealed a pattern of meaning, described as being alienated from oneself and others. Depression is described as an insidious disorder and participants described their experiences variously as elusive, extensive, complex, contradictory, paradoxical and stated that depression pervaded the person's whole lifeworld, involved both body and soul, and affected relationships with others. Relationships with others could be the reason for both wanting to live or to die. How best to confirm this form of suffering is something of a challenge to mental health care professionals.

Involving carers in mental health service development

OBJECTIVE

A project designed to enhance carer participation in a mental health service is described.

METHOD

Carers of people with a mental illness were involved in reviewing and developing policies, and developing a carer rights and responsibilities booklet.

RESULTS

Policies relevant to carers of people with a mental illness were reviewed and updated, and new policies developed to cover existing gaps. Carer and staff awareness of policies was increased. A carer rights and responsibilities booklet was developed.

CONCLUSIONS

Involving carers at this level of service development enhances carer awareness and understanding of the processes involved in a mental health service, and improves staff understanding of carer issues and viewpoints. This process is valuable for mental health services, resulting in positive outcomes.

Psychotherapy and mental health teams

Mental health teams in different configurations and settings are under increasing pressure to offer formal psychotherapies as well as psychologically informed management to large numbers of 'difficult' patients with severe and complex presentations. This pressure has arisen variously from consumers, governmental agencies and commissioning bodies. Although these teams are an important resource, they receive limited training, supervision or support in models of psychotherapy, especially those incorporating a relational dimension and offering a coherent 'common language'. This commonly results in impairment of collective team function, including the quality and consistency of assessments, and may result in stress, splitting and 'burn out' for team members. This situation is due in part to their burden of casework and responsibility but also to prevailing, largely symptom-based and biomedical, models of mental disorder which tend to minimize the importance of psychosocial dimensions in either aetiology or treatment. Formulating and delivering appropriate, evidence-based and robust models of psychotherapy in generic team settings represents a significantly different challenge from that posed by delivery of psychotherapy in specialist settings. Approaches to this important challenge are discussed and summarized drawing on general considerations and the limited direct research evidence, and are illustrated by a cognitive analytic therapy (CAT)-based training project.

Experiences of service user and carer participation in health care education

The agenda of involving service users and their carers more meaningfully in the development, delivery and evaluation of professional education in health is gaining in importance. The paper reports on a symposium which presented three diverse initiatives, established within a school of nursing and midwifery in the United Kingdom. These represent different approaches and attempts to engage service users and in some instances carers more fully in professional education aimed at developing mental health practitioners. Each is presented as achieving movement on a continuum of participation from service users as passive recipients to service users as collaborators and co-researchers. The paper concludes with a discussion of the lessons to be learnt which will hopefully stimulate service user involvement on a wider basis.

'Consumer consultant': expanding the role of consumers in modern mental health services

We aim to increase understanding about issues affecting 'consumer consultants' at an Area Mental Health Service level in the hope that consumers and mental health staff are informed of the challenges and changes associated with that role. Anecdotal feedback indicates that consumer consultants are working harder than ever and that their role is more diverse and challenging than before. Increased organizational demands and responsibilities are testing traditional roles and approaches. There is opportunity for greater sharing of expertise and skills among health professional staff and consumer consultants to enhance current work practices, increase workplace satisfaction, and achieve positive patient outcomes.

Management of self-harm in adults: which way now?

Self-harm remains an important public health problem and two sets of clinical guidelines have been published recently. While these include elements of accepted good practice they are not evidence-based. Further research might concentrate on either very large trials of low-intensity interventions or smaller trials of longer-term psychological treatments. The current management of self-harm may be improved by shifting professionals' views, involving users in staff training, and changing service provision – perhaps moving from risk assessment to needs assessment.