Resources

A 16 minute high definition streaming video in which homeless sector workers discuss their experiences dealing with the deaths of homeless people.

'Working with people to improve their health, welfare and wellbeing can be exceptionally rewarding. These rewards can be even greater when working with vulnerable people or those who for complex reasons have not been reached or helped by mainstream services. One can make a great difference to those who find themselves homeless or disconnected from other natural and health sustaining supports. Our hopes and dreams for people's recovery, or to improve their situation are often realized and this is wonderful. However, sometimes they are not, and few events wound and damage our professional esteem than the death of a service user whom we hoped to help and could not. Such events, and more particularly, the ways they can wound and adversely effect the worker are rarely discussed. This project stemmed from a personal interest in how people deal with traumatizing aspects of work.. I undertook a study exploring the processes involved in dealing with the death of service users, and this package of resources (video, slides and discussion documents) is a way of sharing some of the findings. I hope that the direct quotes of people from the homeless sector and the questions posed in this document will stimulate discussion, assist in service improvement and help people cope with the death of service users so they can maintain hope, move on and continue to provide a necessary and good service to people without being harmed in the process.'

This resource is a product of a collaboration between Dr Richard Lakeman and Dr Evelyn Gordon of Dublin City University and numerous people who work in the homeless sector in Ireland including the initial research participants (quoted throughout, but whose identities remain anonymous), their employers, and advisory group who generously gifted their time (Ciaran Maquire, Erin Nugent, Jimmy Goulding, Grainne Lynch, Barbara Corcoran, Niamh Cullen, Susie O'Keeffe, Anthony Bagnall and Stephen Doyle). This project has been supported by the Homeless Agency and a grant from ESB ElectricAid Ireland.

The PDF links to the final report published at DCU.

Increasing prosperity has not led to a reduction in suicide in most countries and neither has investment in epidemiological / risk factor focused research. Suicide is a pressing public policy issue and social concern but it also reflects an intensely personal struggle. This paper presents a review of the very limited literature examining the suicidal experience from the point of view of the suicidal person. It considers how people live with being suicidal.

Public mental health services in Queensland may be described in many ways but rarely could they be described as trauma-informed or recovery-focused. For our system to be transformed, then systemic issues need to be identified, confronted, discussed and addressed openly and honestly. These include but are not limited to the reality that most individuals who use mental health services in Queensland are coerced and that the most common pathway to mental health services is via coercion. The process of being processed by this coercive system is often highly traumatic. There is an urgent need to restore a sense of safety to service users at every stage of their engagement with health services, and then to focus on stabilisation and resourcing for recovery. The end result might be a salutogenic (rather than a pathologising) culture, whereby mental health services focus on the facilitating the right conditions for restoring and maintain a sense of safety, providing the right therapeutic response in the right dose at the right time, and facilitating recovery.

This part workshop and part presentation acknowledges the crucial role of connection and alliance with people in extreme states to facilitate recovery, growth and wellbeing. Mental health nurses are a unique professional group in that they spend lengthy periods of time with people in extreme states across the lifespan, in varying contexts with mental health and psychosocial problems which may be framed as mental illness. In this workshop the importance of communicating with empathy as a therapeutic tool will be reinforced and highlighted as an essential element of recovery focused and trauma informed care. Participants will be invited to consider how to do this in a recovery focused way in whatever context they might work and with people in extreme states.

This paper addresses the promise of evidence based or research informed mental health care and the reality of everyday practice. No amount of evidence seems to have a great impact on mental health policy and practice unless it is in accord with the dominant discourse of the time. Examples of approaches / projects with a positive evidence base which do or have struggled for recognition include:- psychotherapy, soteria, and open dialogue; Examples of approaches / projects with a poor or negative evidence base which persisted despite the evidence:- insulin Coma Therapy, pharmacological treatment of mild to moderate depression, and maintenance treatment in psychosis. This paper considers what shapes the dominant discourse Mental health service reform and culture and suggests that recovery ought to be a counter-cultural social movement.

Mental health recovery has however been embraced by policy makers in many countries and has become something of a rallying for the current wave of mental health reform. It hints at something good, connoting positive medical outcomes (the person recovered from x), an objective healing process (the person is recovering from x), and a subjective process (I am in recovery). Unfortunately the term has become a catchphrase for all things good and this has attenuated its usefulness. Given the semantic slipperiness of the term it risks becoming a rhetorical device, a term to simply prefix to existing service descriptions or something for activists to demand but not describe how to deliver. If mental health recovery is to be a useful concept for the development of mental health services then what health professionals can do to support mental health recovery needs to be clarified. Some boundaries need to be marked around the concept so that practices which are incompatible with mental health recovery can also be highlighted and their place within reformed mental health services critically considered.
The Irish Institute for Mental Health recovery commissioned this study to help clarify what competencies of mental health professionals are most supportive of mental health recovery. An panel of 31 'experts by experience' who identified as being in mental health recovery rated and commented on 103 competencies according to their usefulness in their own personal recovery (using what is called a Delphi methodology). All the top rated competencies emphasised mental health workers listening to and respecting the person’s view points, conveying a belief that recovery is possible and recognising, respecting and promoting the person’s resources and capacity for recovery. These competencies will be explored and the usefulness of competency statements for mental health recovery will be critically considered.

Accessible summary
What Is Known on the Subject?
Service user involvement in mental health nursing education is beneficial in terms of attitudinal change to reduce stigma, clinical skill development and enhancing understandings of recovery-oriented practice. Service users as experts by experience have not been embedded within pre-registration nursing programs. Consequently, they remain limited in number, ad hoc and frequently tokenistic. Nurse academics responsible for the design and delivery of pre-registration mental health nursing curricula have a potentially important role in facilitating expert by experience involvement in mental health nursing education.
What this Paper Adds to Existing Knowledge
Nurse academics teaching mental health nursing have generally favourable views about the importance of expert by experience involvement. Nurse academics experience significant barriers in supporting the implementation of academic positions for experts by experience, particularly in obtaining funding. The experts by experience could contribute to mental health nursing education does not appear to be clearly understood by nurse academics.
What Are the Implications for Practice?
Mental health services aspire to adopt a recovery-oriented approach to practice. Involving experts by experience in mental health nursing education can facilitate increased understanding and appreciation of recovery-oriented practice. Nurse academics could play an important role in supporting the implementation of experts by experience positions in nursing academia. To do so, they require an understanding of the benefits of EBE involvement in academia and the barriers that can be encountered when attempting to facilitate the implementation of such positions. Experts by experience contribute unique expertise, essential to the development of quality mental health services. Conveying this expertise through the educating the future nursing workforce in mental health is essential.

Abstract
Introduction
Involving service users in mental health nursing education is ad hoc and minimal, despite growing evidence of its benefits. Insights and experiences of nurse academics teaching mental health to pre-registration students have been underrepresented in the research to date.
Aim
To seek insights and experiences of nurse academics involved in designing and delivering pre-registration mental health nursing education in Australian universities regarding involving service users in mental health nursing education.
Methods
A descriptive qualitative study involving 19 nurse academics from 13 Australian universities, involved in pre-registration mental health nursing education. Data were analysed thematically.
Results
Participants reported minimal service user involvement. Most sought an increase and identified barriers. Data analysis resulted in five identified themes: (1) value-rich, (2) resource-poor, (3) imperfect processes, (4) ‘part, but not all’ and (5) unrecognised worth.
Conclusions
Increasing meaningful involvement of service-users in mental health nursing education requires support and investment from multiple stakeholders. Nurse academics are crucial stakeholders in understanding the unique expertise service users bring. Implications for Practice Service users being central to all aspects of mental health services requires their active participation in the education of health professionals. Nurse academics have an important role in realising this goal.

Trauma-informed care has emerged as a prominent strategy to eliminate coercive practices and improve experiences of care in mental health settings, with advocacy from international bodies for mental health reform. Despite this, there remains a significant gap in research understanding the integration of trauma-informed care in mental health nursing practice, particularly when applied to the acute mental health or hospital-based setting. The study aimed to explore the experiences of mental health nurses employed in acute hospital-based settings from a trauma-informed care perspective. The study design was qualitative, using a phenomenological approach to research. A total of 29 nurses employed in acute mental health or hospital-based environments participated. Three over-arching themes were uncovered: ‘Embodied Awareness’: highlighting mental health nursing emotional capabilities are deeply rooted in bodily awareness. ‘Navigating Safety’: signifying spatial elements of fear and how some mental health nurses' resort to coercive or restrictive practices for self-preservation. ‘Caring Amidst Uncertainty’: revealing the relational influences of security guards in mental health nursing. The study reveals a significant gap in trauma-informed care implementation when applied to the context of mental health nursing practice in this setting. Limited evidence on trauma-informed care for mental health nurses, coupled with inadequate workforce preparation and challenging work environments, hinder the effective integration of it. To genuinely embed TIC in acute mental health settings, the study emphasises the need for a thorough exploration of what this entails for mental health nurses.

Many people diagnosed with or presenting with borderline personality disorder (BPD) attend the emergency department (ED) when in crisis, and are often referred to mental health nurses for further assessment, and to arrange appropriate follow-up (MHNs). Little is known about the knowledge, skills, confidence and competence of MHNs working with this group in these specialist roles. This study sought to describe the attitudes of MHNs working in EDs and crisis services towards people who present with symptoms characteristic of BPD and to explore their knowledge of the diagnostic criteria of BPD. A descriptive survey tool comprised of 23 questions was adapted from a previously used survey with clinicians in a mental health service in Australia. Fifty-four nurses who identified as MHNs and were currently employed in EDs or crisis settings completed the survey online. These MHNs were found to hold positive attitudes towards people with BPD including being optimistic about recovery and treatment. The experience and education of MHNs now employed in EDs may have contributed to positive attitudes and self-reported confidence relative to other nurses. Further research ought to focus on how MHNs assist people with a diagnosis of BPD who present in crisis meet immediate needs and facilitate access to effective ongoing care and treatment.

The diagnosis of borderline personality disorder (BPD) has been found to carry stigma and poor hope of recovery. More recently, it has been regarded as a treatable condition through psychotherapy. Despite this, patients often experience lengthy hospitalizations, limited access to treatment, and poor outcomes. This paper describes the experiences of psychiatric nurses working with people diagnosed with BPD in acute mental health in-patient settings in Ireland. Seven nurses were interviewed, and the transcripts were analysed using a reflective and inductive approach. Overall, the nurses did not feel confident that their interventions were effective or valued by the wider service or patients. The nurses articulated their invidious professional circumstances, whereby they were required to act in ways, which ran counter to their vision of therapeutic or recovery-focused work. These views and perceptions that in-patient care is often ineffectual are widely echoed in the literature. We contend that the effect of this circumstance for these nurses approaches moral distress. The nurses were aware of more effective methods of care and treatment for BPD but perceived that they were unable to influence the culture of in-patient care.

The Queensland Government issued a policy directive to lock all acute adult public mental health inpatient wards in 2013. Despite criticism from professional bodies and advocacy for an alternative, the policy has been retained to this day. A blanket directive to treat all psychiatric inpatients in a locked environment without individualised consideration of safety is inconsistent with least restrictive recovery-oriented care. It is against the principles of the United Nations Convention on the Rights of Persons with Disabilities, to which Australia is a signatory. It is also contrary to the main objects of the Mental Health Act 2016 (Qld). Queensland Health has reported a reduction in ‘absences without permission’ from psychiatric inpatient wards after the introduction of the locked wards policy; however, no in-depth analysis of the consequences of this policy has been conducted. It has been argued that patients returning late or not returning from approved leave is a more common event than patients ‘escaping’ from mental health wards, yet all may be counted as ‘absent without permission’ events. A review of the international literature found little evidence of reduced absconding from locked wards. Disadvantages for inpatients of locked wards include lowered self-esteem and autonomy, and a sense of exclusion, confinement and stigma. Locked wards are also associated with lower satisfaction with services and higher rates of medication refusal. On the contrary, there is significant international evidence that models of care like Safewards and having open door policies can improve the environment on inpatient units and may lead to less need for containment and restrictive practices. We recommend a review of the locked wards policy in light of human rights principles and international evidence.

Children who are exposed to trauma often develop difficulties with reflective functioning, affect, and emotion regulation. These problems are thought to arise from and are reflective of disruptions in the process of mentalization, or the human capacity to interpret and reflect upon the thoughts, feelings, wishes, and intentions of oneself and others. This scoping review sought to describe the empirical support for focusing on mentalization processes in psychotherapy for children who have been exposed to trauma. Two independent researchers searched electronic databases, Psychology and Behavioral Sciences Collection, MEDLINE, PsycARTICLES, PsycINFO, and Cochrane. Search terms child, trauma, mentalization and mentalization-based therapy were applied. A total of 425 studies were screened against the inclusion criteria, to include 18 studies comprising quasi-experimental, cross-sectional, naturalistic, case-control, and case studies. In all, 3 themes were identified across the articles: (a) trauma and mentalization, (b) measurement of mentalization, and (c) charting recovery. The literature suggests the role of mentalization treatment in the remission of symptoms for internalizing and externalizing disorders and shaping mentalization deficits over time. Mentalization focused treatments may also improve reflective functioning, emotional regulation capacity and the quality of attachment. The implementation of a child mentalization-based model as a preventative intervention may contribute to increased positive outcomes for vulnerable children. This scoping review presents an overview of the evidence for program developers, mental health services, family support services and those in independent practice that wish to adopt a mentalization approach in child psychotherapy. Future systematic reviews are needed to support this evidence.

Dialectical behaviour therapy (DBT) is an effective treatment for borderline personality disorder and suicidal behaviour. However, it is a complex programme involving individual therapy, participation in skills training groups, and phone coaching aimed at improving emotional regulation, distress tolerance, interpersonal effectiveness, and mindfulness. Little is known about what elements contribute to its effectiveness, or the characteristics of those who complete the programme and achieve recovery. In this study, six participants in a dialectical behaviour therapy programme for youth were interviewed at three time points over their recovery journey. The transcribed narratives were analysed using inductive methods, and the core processes related to recovery were elucidated and described: ‘Becoming a cheerleader for DBT’ and ‘Learning the language of DBT and consolidation of skills’. Indicators of recovery included having a sound working alliance with the primary therapist and others involved in the programme and noticing meaningful improvements in problem areas which they attributed to particular skills and improved capacity to regulate emotions. The rich narrative description provided by participants might inspire some to remain engaged in a dialectical behavioural therapy programme or clinicians to consider promoting a positive view of the prognosis for borderline personality disorder.

There is considerable controversy around psychiatric diagnosis generally and personality disorders specifically. Since its conception, borderline personality disorder has been controversial because of the stigma associated with the diagnosis and the therapeutic nihilism held by practitioners who encounter people with this high prevalence problem in acute settings. This paper reviews the history of the diagnosis of BPD and summarizes some of the controversy surrounding the categorical nature of diagnosis. Both the DSM 5 and ICD-11 will be discussed; however, for the purposes of this paper, the DSM 5 will take the primary focus due to greater cultural significance. Recent developments in the treatment of borderline personality disorder suggest that it is a highly treatable condition and that full clinical recovery is possible. This paper formulates an argument that despite problems with psychiatric diagnosis that are unlikely to be resolved soon, a diagnosis should be made with an accompanying formulation to enable people to receive timely and effective treatment to enable personal and clinical recovery.

Personal responsibility is widely considered important in mental health recovery as well as in popular models of alcohol and drug treatment. Neo-liberal socio-political rhetoric around consumerism in health care often assumes that people are informed and responsible for their own choices and behaviour. In the mental health care context and especially in emergency or crisis settings, personal responsibility often raises particular paradoxes. People often present whose behaviour does not conform to the ideals of the responsible consumer; they may seek and/or be granted absolution from irresponsible behaviour. This paradox is explored and clinicians are urged to consider the context-bound nature of personal responsibility and how attributions of personal responsibility may conflict with policy and their own professional responsibilities to intervene to protect others.

Public policy dictates that, consumers be at the centre of care at all levels of the delivery of mental health services. This has led to a body of research on consumers' views on satisfaction with the care they have received. However, while satisfaction is one measure of outcomes it does not address meaningful change in the consumer’s recovery.
The literature informing this paper indicated that the consumer’s relationship with a nurse was valued and made a contribution to their recovery. There is little detail of how the mental health nurse made a difference to the consumers’ recovery except that it happens within a therapeutic relationship. Unfortunately the concept of 'therapeutic relationship’ is difficult to define and it is not clear, precisely, what it is within that relationship that makes a difference.
This paper argues that while it is useful to investigate the therapeutic relationship and satisfaction with services it is also worth considering the consumer’s view on what is it about their interaction with a mental health nurse that made a difference to their recovery?

The open dialogue approach to crisis intervention is an adaptation of the Finnish need-adapted approach to psychosis that stresses flexibility, rapid response to crisis, family-centred therapy meetings, and individual therapy. Open dialogue reflects a way of working with networks by encouraging dialogue between the treatment team, the individual and the wider social network.
RICHARD LAKEMAN reviews the outcome studies and descriptive literature published in the English language associated with open dialogue in psychosis and considers the critical ingredients. Findings indicate that in small cohorts of people in Western Lapland the duration of untreated psychosis has been reduced. Most people achieve functional recovery with minimal use of neuroleptic medication, have few residual symptoms and are not in receipt of disability benefits at follow-up. Open dialogue practices have evolved to become part of the integrated service culture. While it is unclear whether the open dialogue components of the service package account for the outcomes achieved, the approach appears well-accepted and has a good philosophical fit with reform agendas to improve service user participation in care. Further large scale trials and naturalistic studies are warranted.

Internalized stigma is a complicating feature in the treatment of schizophrenia spectrum disorders and considerably hinders the recovery process. The empowerment and recovery-oriented program of our day clinic might contribute to a reduction in internalized stigma. The aim of the study was to explore the influence of this day clinic program on internalized stigma and other subjectively important outcome measures such as quality of life and psychopathology. Data from two groups of patients had been collected twice, at baseline and after five weeks. The experimental group attended the day clinic treatment (N=40) and the control group waited for the day clinic treatment (N=40). The following significant differences between the two groups were found: Patients in day clinic treatment showed a reduction in internalized stigma while the control group showed a minimal increase (Cohen's d = 0.446). The experimental group as compared with the control group also showed a greater improvement in the quality of life domain psychological health (Cohen’s d = 0.6) and in overall psychopathology (Cohen’s d = 0.452). Interestingly, changes in internalized stigma and psychological quality of life were not associated with changes in psychopathology. Results are encouraging but have to be confirmed in a randomized design.

Aims - Stigma and discrimination related to mental health problems impacts negatively on people's quality of life, help seeking behaviour and recovery trajectories. To date, the experience of discrimination by people with mental health problems has not been systematically explored in the republic of Ireland. This study aimed to explore the experience impact of discrimination as a consequence of being identified with a mental health problem.
Methods - Transcripts of semi-structured interviews with 30 people about their experience of discrimination were subject to thematic analysis and presented in summary form.
Results - People volunteered accounts of discrimination which clustered around employment, personal relationships, business and finance, and health care. Common experiences included being discounted or discredited, being mocked or shunned, and being inhibited or constrained by oneself and others.
Conclusions - Qualitative research of this type may serve to illustrate the complexity of discrimination and the processes whereby stigma is internalised and may shape behaviour. Such an understanding may assist health practitioners reduce stigma, and identify and remediate the impact of discrimination.

The practice, theory, and preparation associated with nursing people with mental health issues has changed in profound ways in recent decades. This has in part been reflected by a shift in nurses identifying as being mental health rather than psychiatric nurses. Context, theory, and values shape what it means to be a mental health nurse. Thirty experienced mental health nurses in Ireland completed a survey on what good mental health nursing is and a definition induced from their responses. Mental health nursing is a professional, client-centered, goal-directed activity based on sound evidence, focused on the growth, development, and recovery of people with complex mental health needs. It involves caring, empathic, insightful, and respectful nurses using interpersonal skills to draw upon and develop the personal resources of individuals and to facilitate change in partnership with the individual and in collaboration with friends, family, and the health care team. This appears to encapsulate the best of what it meant to be a psychiatric nurse, but challenges remain regarding how to reconcile or whether to discard coercive practices incompatible with mental health nursing

This paper considers the ethics, legality and compatibility with mental health recovery and evidence based practice of the enforced wearing of night attire by adults admitted to mental health inpatient facilities. This practice of 'pyjama therapy' continues to persist in some places and is clearly unethical, probably in breach of international human rights law, is antithetical to personal recovery and has no basis as effective in research. Health professionals are urged to consider how in less visible and obvious ways institutional practices, subjugating social dynamics, and demeaning rituals may be played out in encounters with service users.

Background How people integrate the experience of involuntary hospital admission and treatment into their life narrative has not been explored systematically.
Aims To establish a typology of coercion perspectives and styles of integration into life stories.
Method Transcripts of recorded interviews with 15 persons who had previously been involuntarily admitted to hospital were coded and analysed thematically using a modified grounded theory approach.
Results With hindsight, people viewed the experience of involuntary hospital admission as a 'necessary emergency brake', an 'unnecessary overreaction' or a 'practice in need of improvement’. With respect to how they integrated the experience into their life narratives, participants viewed it as 'over and not to be recalled’, a 'life-changing experience’ or a 'motivation for political engagement’.
Conclusions The participants’ diverse and differentiated perspectives on coercive measures and their different styles of integration suggest that people may come to accept coercive measures as necessary when confronted with danger to self or others. However, the implementation of coercion needs to be improved substantially to counteract possible long-term adverse effects.

Although there appears to be a widespread consensus that depression is a ubiquitous human experience, definitions of depression, its prevalence, and how mental health services respond to it have changed significantly over time, particularly during recent decades. Epistemological limitations notwithstanding, it is now estimated that approximately 121 million people experience depression. At the same time, it should be acknowledged that the last two decades have seen the widespread acceptance of depression as a chemical imbalance and a massive corresponding increase in the prescription of antidepressants, most notably of selective serotonin reuptake inhibitors (SSRIs). However, questions have been raised about the effectiveness and iatrogenic side effects of antidepressants; related questions have also been asked about whose interests are served by the marketing and sales of these drugs. Accordingly, this article attempts to problematize the normative orthodoxy concerning depression and creates a "space" in which an alternative can be articulated and enacted. In so doing, the article finds that the search for a world where the automatic response to depression is a pharmacological intervention not only ignores the use of alternative efficacious treatment options but may also inhibit the persons' chance to explore the meaning of their experience and thus prevent people from individual growth and personal development. Interestingly, in worlds analogous to this pharmacologically induced depression-free state, such as utopias like that in Huxley's Brave New World, no "properly conditioned citizen" is depressed or suicidal. Yet, in the same Brave New World, no one is free to suffer, to be different, or crucially, to be independent.

Background Mental health recovery is a concept that is now widely promoted. Lengthy sets of competency statements have been published to assist mental health workers become more recovery orientated in their work. However, there continues to be a lack of clarity around what constitutes recovery focused practice or which competencies are most helpful to assist people towards recovery.
Aims To identify the most important or valued mental health worker competencies/practices that are supportive of mental health recovery.
Method Experts by experience participated in an online Delphi survey to rate the importance of recovery competency statements, to reach consensus on the most important competencies and provide examples of specific practices that demonstrate competent practice.
Result: The top rated competencies emphasized mental health workers listening to and respecting the person's view points, conveying a belief that recovery is possible and recognizing, respecting and promoting the person's resources and capacity for recovery.
Conclusions These results serve to clarify some boundaries around recovery-focused practices and demark these from other examples of good mental health practice.

If early intervention in dementia care is to be enhanced, it is important to have a critical debate over how this should be realized. In this paper, we offer a synthesis of two approaches to care: mental health recovery and person-centred care, and apply them to early-stage dementia care. 'Person-centred care' has become a catchphrase for good dementia care. However, many people have not experienced improvements in care, and other lynch pin concepts, such as 'mental health recovery’, might have utility in driving reform. The similarities and differences between the two approaches are drawn out, and the difficulties of using the word 'recovery’ when discussing a degenerative disease are highlighted. The implications of this discussion for early intervention are discussed. It could be seen that the two bodies of knowledge have much to offer each other, despite initial dissonance with the label of recovery in dementia care.

Mutual self-help groups have a long pedigree in assisting people in mental health recovery. One such group, GROW has quietly been providing a safe, supportive space for recovery for over fifty years and has gone beyond this role in terms of developing community leaders. Research has demonstrated that members assuming leadership roles has been pivotal in sustaining the organisation and that participating in mutual-help has many therapeutic benefits. This paper discusses how GROW develops leadership and outlines a new initiative to assist and recognise leaders in mental health recovery.

Aim This paper is a report of a review of qualitative research to address how people live with suicidality or recover a desire to live. Background. Suicide is a pressing social and public health problem. Much emphasis in suicide research has been on the epidemiology of suicide and the identification of risk and protective factors. Relatively little emphasis has been given to the subjective experiences of suicidal people but this is necessary to inform the care and help provided to individuals.
Data sources Electronic searches of CINAHL Plus with full text, Medline and PsychArticles (included PsycINFO, Social Services Abstracts and Sociological abstracts) were undertaken for the period from 1997 to April 2007. In addition, the following journals were hand searched (1997–2007): 'Mortality', 'Death Studies’, 'Archives of Suicide Research’ and 'Crisis: The Journal of Crisis Intervention and Suicide Prevention’.
Method A systematic review of the literature and thematic content analysis of findings. The findings were extracted from selected papers and synthesized by way of content analysis in narrative and tabular form.
Findings Twelve studies were identified. Analysis revealed a number of interconnected themes: the experience of suffering, struggle, connection, turning points and coping.
Conclusions Living with or overcoming suicidality involves various struggles, often existential in nature. Suicide may be seen as both a failure and a means of coping. People may turn away from suicide quite abruptly through experiencing, gaining or regaining the right kind of connection with others. Nurses working with suicidal individuals should aspire to be identified as people who can turn people’s lives around.

Recent years have seen an explosion of roles for service users within public mental health services and an elevation of some people to celebrity status, based in part on claims of having used mental health services. This paper proposes that there has come to be a hierarchy of service users in relation to perceived insight, power, authority and wealth that parallels and in part perpetuates the power hierarchy within psychiatry and the helping fields. This has not helped many people who use public mental health services. Service users and indeed all people with an interest in promoting mental health should be activists and continue to challenge authority, biomedical hegemony, coercion in mental health services and seek improvements and alternatives for those that use mental health services.

The tradition in many schools of psychotherapy has been the exclusion of people experiencing psychosis or the suspension of psychotherapy when psychosis emerges. In this paper it is argued that those who experience psychosis have a need for psychotherapeutic assistance. Health professionals involved in the care of people with psychosis ought to interact in a psychotherapeutic manner and develop psychotherapeutic skills. The purposes and some selected techniques of psychotherapy along the supportive-exploratory continuum are reviewed and pragmatic considerations when selecting psychotherapeutic interventions are discussed

This paper proposes that some practices and trends in mental health care may be considered as defensive responses to collective anxiety and fear. On a larger scale similar dynamics occur around fear of terrorism. Collectively and individually we are pulled by the defensive forces and dynamics associated with anxiety. This can in part explain the polarization that occurs around issues of definition and response to mental illness. Fear and anxiety push services towards simplistic viewpoints and futile practices. Pluralism, humility and the capacity to view things from the perspective of others may help in channelling anxiety productively.

Routine 'outcome measurement' is currently being introduced across Australian mental health services. This paper asserts that routine standardized outcome measurement in its current form can only provide a crude and narrow lens through which to witness recovery. It has only a limited capacity to capture the richness of people’s recovery journeys or provide information that can usefully inform care. Indeed, in its implementation nurses may be required to collude in practices or account for practice in ways which run counter to the personal recovery paradigm. Nurses should view a focus on outcomes as an opportunity for critical reflection as well as to seek ways to account for recovery stories in meaningful ways.

Hearing voices is a common occurrence, and an experience of many people in psychiatric/mental health care. Nurses are challenged to provide care, which is empowering and helps people who hear voices. Nursing practice undertaken in partnership with the voice hearer and informed by a working explanatory model of hallucinations offers greater helping potential. This paper uses Slade's (1976. The British Journal of Social and Clinical Psychology 15, 415-423.) explanatory model as a framework for exploring interventions which may assist people in exerting some control over the experience and which might be used alongside pharmacological interventions. Principles and practical ideas for how nurses might assist people to cope with and make sense of the experience are explored.

A system of mental health care is not an unattainable goal, but it is a challenging one.. one which is necessary to pursue if we are serious about mental health.

Australia is currently in lockdown, it’s State, and National borders closed, gatherings of more than two people in public are banned, and a raft of other unprecedented measures have been implemented in response to the COVID‐19 pandemic. This comes on the back of apocalyptic fires, floods and cyclones. Those that have been involved in recovery efforts in any of these events will have been witness to the resilience of the Australian community. These adventitious crises tend to bring communities together. This pandemic poses quite a different existential, psychological and social threat to Australians…

This editorial explores particular forms of epistemic injustice which mental health service users may be exposed to. Mental health service provision throws up some particular problems in relation to developing and sustaining just services. Like the problems which people bring with them to mental health care, justice is multifaceted and multidimensional. Whilst often it may seem that addressing injustice is too big a problem for any but the most heroic of individuals, much injustice is underpinned by testimonial injustice of various kinds which we as health professionals are implicated in perpetuating. Mental health professionals need to reflect on the way we engage with service users, consider their testimony and construct problems. To do so will have far reaching implications for creating just institutions and ultimately just societies.

Quality mental health service delivery is increasingly focused on providing a recovery oriented and rights-based approach to care. Achieving this aspiration will require ‘the right number and equitable distribution of competent, sensitive, and appropriately skilled health professionals’ (WHO, 2021, p4). Given nurses typically make up the largest occupational group within healthcare settings, their impact on future mental health service delivery is arguably the greatest. Therefore, it is necessary to examine how adequately prepared nurses working in mental health settings are, and the implications of current approaches for mental health service users.

We compared the minimal education requirements to work as a registered nurse in a mental health setting in five countries: Australia, Ireland, Germany, Denmark and France. Through clarification and comparison, we found profound differences in course accreditation, curriculum content, hours of supervised placement, assessable competencies, support for transition to practice, and protected legal title on completion of the course. Given these differences, it is concerning that once registered, scope of practice is similar across all five countries; even though the registering bodies in four of the countries do not recognize mental health nursing as a sub-speciality within the discipline of nursing.

Of the five countries compared, Ireland is the only country to acknowledge mental health nursing as a sub-speciality within the discipline of nursing; nurses are prepared, registered, and legally recognized as Psychiatric Nurses. This approach creates mental health service delivery where service users and families can be assured that the nurse caring for them has been educated and assessed against standardized competencies determined by the Nursing and Midwifery Board Ireland and has undertaken prescribed supervised clinical hours in mental health settings. In comparison the minimum requirement to work in mental health services in Australia, Denmark, France and Germany is general nursing registration. With varying amounts of mental health content and practice requirement incorporated into general nursing courses.

Mental health service users have a right to meet nurses with required competencies to deliver evidence based, recovery-oriented care. If nurses are to lead and impact on future mental health service delivery, we must begin by adequately preparing mental health nurses.

For many mental health services, the provision of ‘trauma-informed care’ is a virtue-signalling but distant aspiration. This presentation will outline how a private mental health service, AVIVE has reimagined mental health care so that all inpatient service users can access an evidence-based, trauma-informed and recovery-focused programme integrated with their psychiatric treatment. Specifically, this presentation will focus on the role of mental health nurses in supporting people on their journeys to wellness. This includes providing a staged, open group programme and focused psychotherapeutic time with people to support the development of a personalized recovery and relapse prevention plan developed by the author.

The therapeutic programme is firstly focused on restoring and maintaining a sense of safety. All staff in AVIVE facilities will be trained and supervised to facilitate these conditions. The first week of the inpatient group program focuses on skills and practices to restore a sense of safety and develop and practice distress tolerance and emotional regulation skills. The group then aims to facilitate and strengthen the development of personal and social resources to support treatment, improve well-being, and lead a thriving life. Mental health nurses will support people (including families and supporters) on this recovery journey. The evidence to support this approach (which is drawn from the polyvagal theory, positive psychology and nursing theory) will be outlined and strategies to evaluate effectiveness discussed.

Many people diagnosed with or presenting with Borderline Personality Disorder (BPD) attend the emergency department (ED) when in crisis. There is limited understanding of how mental health nurses (MHNs) within EDs perceive the diagnosis of BPD or make sense of the constellation of behaviours and symptoms associated with BPD and how attitudes influence the conferral of a provisional diagnosis of BPD. We aimed to identify the attitudes held by mental health nurses working in emergency and crisis settings towards people who present with symptoms characteristic of BPD. We also aimed to explore the defining symptoms and behaviours that indicate a diagnosis of BPD as perceived by MHNs working in emergency and crisis settings. A descriptive survey tool composed of 23 questions was adapted from a previously used survey tool deployed on clinicians in a mental health service in Australia. Fifty-four nurses who identified as MHNs and were currently employed in EDs or crisis settings completed the survey online.
MHNs who work in emergency and crisis settings were found to hold positive attitudes towards people with BPD, including being optimistic about recovery and treatment and non-punitive or blaming in relation to presenting behaviour in emergency or crisis contexts.
The changing nature of presentations to the emergency department and the increase in education for nurses may have attributed to the positive change in attitudes. Further research using a validated tool with a larger sample size should be afforded to explore the attitudes, knowledge, and confidence of MHNs in the ED. Research might also explore how MHNs in these contexts facilitate an effective response, facilitates ongoing treatment goals, and recovery.

Watch this facilitated panel discussion of Cynthia's story to be better equipped to:
• describe the common symptoms and causes associated with schizophrenia
• identify the challenges, merits and opportunities in evidence-based approaches deemed most effective in treating and supporting people experiencing schizophrenia
• facilitate clinical and personal recovery in a primary care setting for people who may experience psychosis or be diagnosed with schizophrenia.

This presentation presents selected findings from the 2012 survey of Mental Health Nurses working within the Mental Health Incentive Programme (MHNIP). This survey provides a profile of a workforce that is exceptionally well educated and experienced. It paints a picture of nurses working collaboratively to deliver specialist services to under or poorly served populations in primary care settings. In particular the program has enabled the flexible delivery of forms of psychotherapy, recovery focused care, improved case co-ordination and a more acceptable interface between the individual and other branches of the health and welfare system.

What is mental health nursing? What if anything distinguishes it from psychiatric nursing and what constitutes good rather than merely good enough mental health nursing? Text books on nursing rarely address these questions and tend to treat psychiatric, mental health and various combinations thereof as synonymous in their titles and in discussion. Surely, however, what mental health nursing is and what mental health nurses do, goes to the very heart of professional identity? This project sought to discover what 'good mental health nursing' is as described by expert practitioners. Thirty members of the Irish Institute of Mental Health Nursing completed an on-line survey and their responses were subject to a content analysis whereby all content was captured in a broad definition. Mental health nursing was described as a professional, client centred, goal directed, evidenced based activity focused on the growth, development and recovery of people with complex mental health needs. It involves caring, empathic, insightful and respectful nurses using interpersonal skills to draw upon and develop the personal resources of individuals and to facilitate change in partnership with the individual and in collaboration with friends, family and the health care team.

A common understanding in mental health care is that good medicine (and arguably good allied health, nursing and social care) is founded on a thorough assessment, leading to a diagnosis which then dictates or at least informs what kind of treatment or care ought to be provided. However, this simple heuristic is problematic in psychiatry. Psychiatric diagnosis are essentially descriptive labels which have utility for researchers and health professionals in terms of communication, but they don't presume anything (although we often assume much) about aetiology or prognosis and therefore are a poor foundation for treatment and care. Much has also been made of the damaging, stigmatising effects of being psychiatrically labelled and engulfed in a patient role. Nevertheless a commitment to the ethical principle of veracity and to evidence based practices such as psycho-education seem to require that service users be informed of and educated about their diagnosis. This presentation considers a different problem associated with telling people what is wrong with them. That is, naively following the assessment-diagnosis-treatment heuristic may perpetuate forms of epistemic injustice: Diminishing the person as an informant and person with capacities (a grievous harm in it-self) but it may also prematurely foreclose on opportunities to make sense of experience and discover the best solutions to problems. Whether we share a psychiatric diagnosis or not with service users (and I'm not suggesting that communicating diagnosis is inherently wrong) it is crucially important for the wellbeing and recovery of service users that diagnosis are offered tentatively and that both they and health professionals engage in an ongoing process of exploration and discovery.

Once upon a time psychiatric nurses worked in psychiatric hospitals, providing most of the direct care to patients and carrying out delegated medical tasks and whatever else was needed. Nowadays the division of labour is rarely so simple with nurses and indeed many allied health professionals assuming a diversity of specialised and often similar roles in a variety of settings. Further muddying the waters are movements such as 'evidence based practice' and 'mental health recovery' that traverse interdisciplinary boundaries and sometimes conflict with the everyday practices that some nurses engage in. Defining what mental health nursing is has never been harder. Determining what good or 'good enough' mental health nursing might be considered similar to the quest for the Holy Grail. Scholars (knights and heroes) have looked to philosophy, and grand theory to determine what mental health nursing is. This paper reports on a survey of members of the Irish Institute of Mental Health Nursing and their views on good mental health nursing. It then considers how these views might inform the quest and what might distinguish the Holy Grail from other artefacts.

The stigmatising, dehumanising and destructive side of institutional care (including psychiatric care) has been the subject of extensive and sustained critique for many years. This has fuelled a drive towards reform in systems of psychiatric care and a renegotiation of the social contract between health professionals and service users. Nevertheless, people who are presumed to have a mental illness continue to suffer many indignities and injustices at the hands of those that purport to care for them. This paper draws on the worker of Fricker (2007) and outlines two forms of epistemic injustice and how they may apply in everyday mental health care and impede genuine and positive mental health reform. The first 'testimonial injustice' occurs when a people's testimony is given reduced credibility, thus diminishing them as an informant or giver of knowledge. The second which is elaborated in more detail is 'hermeneutical injustice', or a social situation in which a collective hermeneutical gap prevents a person from making sense of an experience which is strongly in their interests to render intelligible. The paper then considers how nurses can engage in mental health care that embodies and promotes justice.
Fricker, M. (2007). Epistemic Injustice: Power and the Ethics of Knowing. Oxford: Oxford University Press.

The impact that movies have had on the public perceptions of madness cannot be underestimated. Iconic movies such as 'One Flew Over the Cuckoos Nest' captured the zeitgeist of the time, both reflecting and fomenting a healthy disrespect for authority and a suspiciousness of total institutions. The way madness is represented in the movies also in part reflects our views and fears of madness. The characters can evoke our sympathy or provoke horror. Movies can play a role in reinforcing stigma, and perpetuating falsehoods, but conversely they may normalise some experiences, evoke empathy, spur people to action and capture truths of how mental distress and problems of living are conceived. This presentation invites people to the movies, to view some Oscar winning and B grade performances which illustrate how conceptions of mental health have changed. At a time when incapacity legislation is being debated these snippets can be informative as to the extent to which people's capacity is under-estimated, the shifting nature of psychiatric diagnosis, and gaps in our collective social imagination perpetuate various forms of injustice. They can also be fascinating and fun!

Here we extrapolate and expand on arguments made in a published paper written by the three speakers (Lakeman, McGowan and Walsh, 2007). During the 1960s and 1970s the mental health service user movement was united with other human rights movements associated with the emancipation of women, racial equality and the general promotion of liberty. Public demand to reform the care and treatment of patients was underpinned by principles of universal human rights and equality. The public gauze turned towards mental hospitals/asylums and other social institutions (outside-in) with an increasingly critical eye. Over time partnerships and collaborations between service users and public health bodies have been established whereby change is promoted from within services (inside-out) and this apparent collegial/collaboration between service users/staff lends a veneer of respectability to mental health services. The hard edge of the service user movement has been 'softened' as an ever increasing number of activists have moved from the streets into the board room (often into paid positions). Barker and Buchannan-Barker (2001) suggest that a consequence of this might be that service users have become ineffectual in their attempts to instigate change as they have become assimilated into a system they once resisted. Campbell (2001) suggests that service users lost their sense of citizenship during this period of transition and for many service users their social position, prospects, and health outcomes are unimproved since the era of the asylum. We point out that a hierarchy of power and influence has evolved between the 'professional’ and ordinary service user that parallels that of the health 'professional’ and service user. We believe that the power to resist and instigate change has been weakened and that there remains a place for public protest independent of services and would-be gurus.

Barker P, Buchanan-Barker P (2003) Death by assimilation. Asylum. 13, 3, 10-12.
Campbell, P (2001) The role of users of psychiatric services in service development - influence not power. Psychiatric Bulletin. 25 (3) 87-88.
Lakeman, R., McGowan, P., and Walsh, J (2007) Service users, authority, power and protest: A call for renewed activism. Mental Health Practice, 11 (4) 12-16

People who may be considered 'psychotic', 'disordered' or 'deluded' are often excluded from formal psychotherapy. Nevertheless, the everyday interactions between people can be helpful and therapeutic. This workshop focuses on introducing and practicing a basic model of empathic communication at the supportive end of the psychotherapeutic continuum that might be employed when people express bizarre or contrary ideas.

The discourses that compete to shape mental health service provision may broadly be divided into those that emphasise individual difference, diversity and mystery and those that emphasis sameness or homogeneity and predictability. Practices such as case-mix determination, standardised outcome measurement, and the standardisation of treatment are vigorously promoted within mental health services (see: Australian Mental Health Outcomes and Classification Network, 2004). The arguments for these are seductive. They promise certainty, meet managerial demands for more and better information, cement the role of health professional as expert and facilitate a certain kind of evidenced based practice. This paper raises questions about the compatibility of these practices and their underlying assumptions with the promotion of personal recovery, the notion of people and groups as complex, therapy as a process of discovery, and the stance of the health professional as one of humility. Discourse is created and perpetuated by those who have the power and means of communication (Foucalt, 1973). This paper argues that logic, reason and 'evidence' alone will not derail current trends towards managed and homogenised care. Real change may only happen when consumers, carers and compassionate health professionals present a loud enough counter-case and are heard and respected.

Foucalt, M (1973). The birth of the clinic: An archaeology of medical perception. New York: Pantheon
Australian Mental Health Outcomes and Classification Network. (2004). MHNOCC.ORG - Home. Retrieved 24/2, 2006, from http://www.mhnocc.org/

Before the end of 2003 Queensland Health will require ''outcome measures" to be undertaken for all patients of mental health services. This paper provides a critical reflection on the use of outcome measurements and selected aspects of Queensland Health's implementation. Using the metaphor of religion this paper will challenge some of the articles of faith that outcome measurement is founded upon and pose questions about the compatibility of these with other systems of belief which inform the recovery movement and which are fundamental to humanistic nursing care

Hearing voices is an experience common to many people in psychiatric care but meaningful help in coping with the experience is less common. This paper presents a model of coping behaviour specific to hearing voices. It proposes that coping with voices includes hallucinatory control, emotion and problem focused coping and is a function of context, the features of voices, and beliefs about voices. Results from a pilot study exploring coping with voices are presented. A questionnaire which combined previously tested scales including voice topography (Hustig & Häfner, 1990), beliefs about voices (Chadwick & Birchwood, 1995a) and general coping behaviour (Carver, Weintraub & Sheier, 1989) was administered to 10 consumers of a mental health service with a recent history of hearing voices. The instruments were found to be reliable and easy to complete. Results are discussed in relation to the theoretical framework and suggest that people engage in a wide range of purposeful coping behaviour in response to voices that do not fit comfortably into arbitrary coping categories. Consideration of 'coping with' rather than 'amelioration' of voices ought to be a key focus of nursing, and the model of coping presented may be useful in making sense of, and facilitating coping behaviour.

It is our belief, that the experience of emotional or psychological distress, or mental illness can lead to a much greater positive outcome than merely recovering what has been lost… It can lead to discovery… discovering something about what it means to be person. Personal discovery we believe is an important component of recovery and being as well as being an effective helper.