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Valuing Psychotherapy and Mental Health Nursing

Mental health nursing is one of the oldest regulated health professions in the world. It predates the invention of all other allied health professions. At the core of it's history and practice is psychotherapy. Psychotherapy is a transdiciplinary activity. In my country of residence of Australia, neither psychotherapy, nor mental health nursing are treated respectfully.

Psychotherapy is often conflated with psychology and mental health nurses are viewed as having few skills in either. Psychotherapy is the treatment for most problems of living and has been for most of the 20th century. This page celebrates and promotes psychotherapy as sometimes the only effective treatment for mental health problems, and also mental health nursing as a specialty which is often excluded from practicing this craft in Australia, despite often being experts in the field.

Unlocking the potential of Mental Health Nurses by enabling access to the MBS (A petition)

Credentialed Mental Health Nurses (MHNs) in Australia are highly skilled, and educated Mental Health Professionals. All have postgraduate qualifications and many are experts in the provision of psychotherapy including working with those with the most complex health issues (see: 1, 2, 3). Successive Governments have failed to recognise the expertise or potential of MHNs. What was formerly known as the Mental Health Nurse Incentive Programme (MHNIP) offered some of the most vulnerable in the community access to medium to long term psychotherapy (see: 4,5) despite this not being officially recognised (see: 6). The MHNIP was handed to the Primary Health Care Networks (PHNs) as part of their flexible funding pool and any reference to the therapeutic capability of MHNs removed from the guidance notes on 'Stepped Care' (see: 7). Some PHNs have prevented MHNs from continuing to provide care to those in need. MHNs have been locked out of providing care under the Medicare Benefit Scheme including COVID-19 funding for tele-health measures (see: 8, 9). MHNs should have full access to the MBS, and their therapeutic skills recognised by all funders of mental health services.

The case for equitable access to mental health nurse psychotherapists: improving access and outcomes across the mental health continuum.

  • The Medicare Benefit Scheme (MBS), ‘Better Access’ program which focuses on providing subsidized focused psychological strategies is out of reach for large sections of the population due to the overvaluing of this service by eligible providers who charge excessive ‘gap fees’. Mental health nurses (whilst eligible through PHN funded programmes to provide services for people with higher level needs or when people can’t afford ‘gap fees’) have been excluded from the MBS. Additionally, eligibility to provide ‘Better Access’ has become the de-facto benchmark to provide other MBS items (e.g. the recent eating disorder Item Numbers) and a criteria for employment in many services such as headspace.
  • Mental health nursing is one of the oldest regulated professions, most trusted, and with a strong history and tradition of providing psychotherapy to those with the most complex needs. Surveys of mental health nurse psychotherapists in Australia indicate that they are highly trained (generally with Masters level qualifications specifically in psychotherapy) and often have decades of experience providing psychotherapy to vulnerable groups.
  • The public have been unfairly excluded from being able to access a subsidized service from Mental Health Nurses who may be the most experienced and able providers; MHNs have been unfairly discriminated against in primary care by being unable to earn a living providing skilled services in competition with often less skilled yet subsidised practitioners.
  • Granting immediate eligibility to MHNs to claim the MBS will address a serious skills shortage in primary care across the continuum of stepped care without the need for any further investment in training or education of health professionals.

Lakeman, R.,Hurley, J., & Ryan, K. (2014). Submission to the National Mental Health Commission’s Review of Mental Health Services and Programmes 2014. Australian College of Mental Health Nurses: Canberra

Mental health nurses play a pivotal role in the provision of mental health care and, as such, are well placed to comment on gaps in access to services, workforce needs and the inability of mental health nurses to work to their full scope of practice.

Lakeman, R. (2007, 10-12 September). Surviving being suicidal: What money can't buy and statistics can't tell us. Paper presented at the Thinking, Feeling, Being: Critical Perspectives and Creative Engagement in Psychosocial Health, Dublin City University, Ireland.

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.

Lakeman, R. (2020, 14 October). Trauma informed care and the challenge of changing cultures of acute mental health care. [Keynote] Paper presented at the 'Trauma informed transformations: Cultural and psychological safety for all' Online conference, Agency for Clinical Innovation

That there is a chemical imbalance to be addressed in mental illness is false… That mental illness is a problem of brain circuitry is speculation… That most people who present to mental health services have a history of trauma or adverse childhood experiences is a fact. This paper discusses the implications of accepting these truths on mental health service culture and the challenges associated with realising trauma informed care in a coercive, heirarchical, medicocentric, and risk averse culture.

Lakeman, R. (2018, April 13-14) Discussion on viable solutions for the mental health workforce - A Panel Discussion. Presented at the 2018 Primary Care Conference: Are We Ready For The Future? ACMHN. Novotel St Kilda, Melbourne

Richard recently published a dystopian picture of mental health nursing (Lakeman & Molloy, 2017) and argued that mental health nursing has become a zombie category. Richard acknowledges but will not reiterate the historical antecedents that have led to this state of affairs or belabour the resilience and tenacity of a few mental health nurses to carve and sustain a niche in primary care. Nursing may well have longevity in state run institutions where few other occupational groups want to work. However the survival or resurrection of mental health nursing as a specialty depends on assuming a respected and valued (equitably remunerated) presence in primary care settings.

Eimear Muir-Cochrane presented her view points and the moderator was Richard Gray.

Lakeman, R. (2014, March 27-28). Lost in translation: Research, recovery and the relationship (keynote). Paper Presented at the '2nd International Psychiatric Congress: Mental Health & Recovery' [Internationaler Psychiatriekongress:zu seelischer Gesundheit und Recovery]. University Bern Psychiatric Services. Switzerland

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.

Lakeman, R. (2002, 18-20 September). Psychiatric nursing in a shrinking world: The impact and implications of the Internet and computer mediated communication on the field of psychiatric nursing practice, research and education (Plenary Paper). Paper presented at the 8th International NPNR Conference, "Research Journeys: Travelling Together", St Cross Building, University of Oxford.

Within the last decade computer mediated communication (CMC) facilitated by the growth of the Internet has transformed the way many people relate to each other and their world. In a metaphorical but very real way the world has become a smaller place in which distance and time may be transcended and bridges between cultures are built at a keystroke. The rapid growth in this area of technology and the exponential growth of internet usage poses a challenge to traditional notions of identity and community which are central constructs in the theorising and practice of psychiatry, psychotherapy and psychiatric nursing. This paper considers the impact and implications that CMC might have on the field of psychiatric nursing education, practice and research.

Lakeman, R. (2021). Psychology belongs to everyone, but what about psychotherapy? A discussion of the undervaluing and professional capture of psychotherapy in Australia. The Science of Psychotherapy Magazine, Feb 2021, 41-77.

Australia has made a huge investment in mental health through subsidised medical and psychological services in primary care. However, subsidised psychotherapy of any degree of sophistication is rarely available in the right dose, at the right time, or delivered by people that have advanced training in psychotherapy. Indeed, in Australia psychotherapy is not part of the public discourse about treatment and is often conflated with or presumed to be the same as psychology. This paper discusses the Australian funding context and argues that psychotherapy needs to be valued and assume its rightful position as essential ‘treatment’ commensurate with the value placed on medicine and medicines.

Lakeman, R. (2020). Sisyphus and the struggle for recognition of Mental Health Nursing (Feature Article), Summer News 2020, Year in Review. The Australian College of Mental Health Nurses, p.3-9, Online: https://www.flipsnack.com/acmhn/acmhn-yearinreview.html

Albert Camus used the myth of Sisyphus to illustrate his philosophy of the absurd. Having scorned the Gods, Sisyphus was destined to roll or carry a rock up-hill each day, and then watch it roll back down, repeating this struggle each day for eternity. This myth captures the ongoing struggle that mental health nurses (MHNs) have in realising any meaningful recognition of the skills they possess or even that they exist at all. This opinion piece is part reflection on the past year which commenced with catastrophic bushfires which was followed by COVID and an unprecedented need for a psychotherapeutic response from competent practitioners skilled in psychotherapy. MHNs were excluded by the Australian Government from providing subsidised psychotherapeutic services. These challenges facing MHNs are entwined around recognition of the psychotherapeutic capabilities of MHNs, the instrumental relationship of nursing to medicine and the challenges of working in a hierarchical and highly coercive care system, and lastly how entrenched managerialism and the trend towards centralised and protocol driven practices has impacted on professional autonomy. Mental health nursing as a specialty faces an existential crisis which will not be resolved until their psychotherapeutic potential is recognised and MHNs have parity of access to the medicare benefits scheme as often lesser skilled practitioners currently do.

Campbell, K., & Lakeman, R. (2020 Early View). Borderline Personality Disorder: A Case for the Right Treatment, at the Right Dose, at the Right Time. Issues in Mental Health Nursing, 1-6. https://doi.org/10.1080/01612840.2020.1833119

There is now compelling evidence that a range of psychotherapeutic treatments are effective in the treatment of borderline personality disorder (BPD). Such treatments are often lengthy, expensive, subject to high rates of incompletion and are rarely available to people with sub-threshold symptoms. There is broad agreement that some combination of vulnerability, invalidating environment, childhood adversity, disrupted attachment in childhood or trauma play a role in the aetiology of the syndrome of BPD. These factors also contribute to problems with the capacity to mentalise, regulate emotions, tolerate distress and impact on psychosocial development with or without self-damaging and suicidal behaviour. This column takes as a given that people with BPD should receive evidence-based psychological treatments such as dialectical behaviour therapy (DBT), interpersonal therapy and cognitive behavioural therapy in a sufficient dose to be helpful. However, to avert an escalating trajectory which may lead to a diagnosis of BPD the right dose of the right therapy at the right time is necessary. Under-dosing or ineffective psychotherapy can be potentially harmful. This column reviews the evidence, such as it is, for therapeutic approaches which may contribute to more skilful negotiation of life?s difficulties and which may avert deterioration in mental health and quality of life in vulnerable individuals and families.

Lakeman, R., & Crighton, J. (2020 Early View). The Impact of Social Distancing on People with Borderline Personality Disorder: The Views of Dialectical Behavioural Therapists. Issues in Mental Health Nursing, 1-7. https://doi.org/10.1080/01612840.2020.1817208

Dialectical Behavioural Therapy (DBT) is an evidence-based treatment for borderline personality disorder and other problems associated with emotional dysregulation. It has traditionally been deployed as a face-to-face programme comprised of attendance at group skills training, individual therapy and phone coaching. Social distancing measures arising from the COVID-19 pandemic led to a cessation of therapeutic programmes in many places. This survey of DBT clinicians in a regional State mental health service in Australia explored the impact of the cessation of DBT programmes in the region and obstacles to engaging with people via online platforms. Clinicians have been able to engage in DBT informed care, but it was perceived that many people have experienced a clinical deterioration or have increased their use of crisis services, which is entirely appropriate, as group skills programmes have ceased. Movement to online platforms of delivery poses problems, as some people do not have the access to internet or privacy in their home environments to engage in online therapy. Ideally, clinicians need to be supported through education, supervision and coaching in the use of telehealth interventions. Social distancing requirements has enabled an opportunity to carefully consider how programmes can be adapted to enable the extension of these programmes to those who have traditionally been unable to access them.

Oehlman Forbes, D., Lee, M., & Lakeman, R. (2020). The role of mentalization in child psychotherapy, interpersonal trauma, and recovery: A scoping review. Psychotherapy. Advance online publication. https://doi.org/10.1037/pst0000341

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.

Hocke, B., & Lakeman, R. (2020). ATSI: What's in a name? And why does it matter? The Science of Psychotherapy, Summer, 44-49.

This paper is in response to the essay International Trauma: History, Theory and Practices for Change published in the July edition of this magazine and specifically the use of the acronym “ATSI” used occasionally in this otherwise timely and thought-provoking paper. We would like to begin with some personal reflections on the use of the acronym ATSI before moving on to more cerebral considerations about what this has to do with psychotherapy.

Lakeman, R., & Emeleus, M. (2020). The process of recovery and change in a dialectical behaviour therapy programme for youth. International Journal of Mental Health Nursing, 29(6), 1092-1100. https://doi.org/10.1111/inm.12749

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.

Hurley, J., Lakeman, R., Cashin, A., & Ryan, T. (2020). Mental health nurse psychotherapists are well situated to improve service shortfalls in Australia: findings from a qualitative study. Australasian Psychiatry, 28(4), 423–425. https://doi.org/10.1177/1039856220924326

Objective
This paper reports the capabilities of mental health nurse (MHN) psychotherapists in Australia and their perceptions on how to best utilize their skills.
Method
An MHN is a registered nurse with recognized specialist qualifications in mental health nursing. One hundred and fifty three MHNs completed an online survey; 12 were interviewed.
Results
Three themes were derived from a qualitative analysis of the aggregated data: psychotherapy skills of MHN psychotherapists are under-utilized; these nurses bridge gaps between biomedical and psychosocial service provision; and equitable access to rebates in the primary care sector is an obstacle to enabling access to services.
Conclusions
MHN psychotherapists are a potentially valuable resource to patients in tertiary and primary health care. They offer capacity to increase access to specialist psychotherapy services for complex and high risk groups, while being additionally capable of meeting patients’ physical and social needs. Equitable access to current funding streams including Medicare rebates can enable these outcomes.

Campbell, K., Clarke, K.-A., Massey, D., & Lakeman, R. (2020). Borderline Personality Disorder: To diagnose or not to diagnose? That is the question. International journal of mental health nursing, 29(5) 972-981. Doi:10.1111/inm.12737

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.

Lakeman, R., Cashin, A., Hurley, J., & Ryan, T. (2020). The psychotherapeutic practice and potential of mental health nurses: an Australian survey. Australian Health Review,44(6), 916-923, doi.org/10.1071/AH19208

Objective:Mental Health Nurses (MHNs) have an under recognised long history of engaging in psychotherapeutic practice across the spectrum of mental illness and mental health problems, including those with serious mental health problems. There is a need for a psychotherapeutic response for people with complex or serious mental health problems within the stepped care model. This project sought to identify the educational preparation and self-reported competency of MHNs to clinically undertake psychotherapy with people.
Methods: Situated within a larger mixed method study exploring how MHNs practice psychotherapy, adapt it to routine care and envisage the future, this paper reports the findings from survey of MHNs regarding their educational preparation, experience and competence in modalities of psychotherapy and the application of psychotherapy with specific clinical groups.
Results: 153 MHNs responded to a request to participate. In this cohort, eighty-seven per cent of nurses had postgraduate qualifications specific to psychotherapy. Ninety-five per cent had worked for over 10 years in the mental health field and had hundreds of hours of training in psychotherapy. There was a high level of self- reported competence in working with people with serious mental health problems and ‘at risk’ or vulnerable groups.
ConclusionsCurrently, MHNs are not recognised in federal funding arrangements to procure psychotherapeutic intervention for members of the Australian population who require it. MHNs ought to be recognised as independent providers based on both the psychotherapeutic skills that they possess and their specialist clinical skills of working with people across the spectrum of mental health problems. Appropriately qualified MHNs need to be funded to employ their skills in psychotherapy via access to appropriate funding arrangements such as Better Access and the National Disability Insurance Scheme.

Lakeman, R., Emeleus, M., Davies, S., & Anderson, S. (Early View 2020) A pragmatic evaluation of a high-fidelity Dialectical Behaviour Therapy programme for youth with borderline personality disorder, Advances in Mental Health. P.1-11. doi:10.1080/18387357.2020.1761262

Objective: This paper describes and evaluates a high-fidelity Dialectical Behaviour Therapy (DBT) programme for youth (15-25 years). The project was undertaken as a partnership between public mental health services and a non-government organisation in regional Australia. DBT is an evidence-based treatment for Borderline Personality Disorder (BPD) but is rarely accessible within public mental health services.
Method: Participants completed an Adverse Childhood Experiences (ACE) questionnaire, repeated measures of the Borderline Symptom List (BSL-23), supplementary behaviour questionnaire (BSL-Supp) and general well-being questionnaires. Hospital and emergency service use was examined for the year prior to referral to the programme and for the year following completion. The characteristics of those people who did not complete the programme were also described.
Results: Borderline personality symptoms were correlated with the number of reported adverse childhood experiences. Participants who remained in the programme for at least twelve weeks had significant reductions in BSL-23 scores with several reporting no symptoms after completing the programme. Participants had high rates of hospital and emergency department use in the year prior to participation and significantly less use in the year following completion.
Discussion: It is feasible to deliver a high fidelity DBT programme and achieve reductions in symptoms and use of hospital and emergency services in a regional public mental health service.

Hurley, J., Lakeman, R., Cashin, A., & Ryan, T. (2020). The remarkable (Disappearing Act of the) mental health nurse psychotherapist. International journal of mental health nursing, 29(4), 547-750. Doi:10.1111/inm.12698

The aim of this Australian based qualitative study was to better understand key drivers for mental health nurses to undertake training in psychotherapy, and how these capabilities are integrated into their clinical practice. Open ended reposes from a national survey of 153 mental health nurses were supplemented with data from 12 semi-structured interviews of nurses with rich experience of integrating psychotherapy and mental health nursing capabilities. Key findings emerging from the thematic analysis were that mental health nurses are providing uniquely holistic psychotherapeutic services to consumers with often complex conditions, despite overtly hostile clinical and policy contexts. These often very well qualified mental health nurse psychotherapists are different to the traditional identity of either a nurse or psychotherapist. Recommendations from the findings of this study are that where appropriately qualified, mental health nurses be granted eligible provider status for existing Medicare funding items. Finally, training and building foundational capabilities in psychotherapy is highly recommended for all mental health nurses.

Lakeman, R. (2020). Advanced empathy: A key to supporting people experiencing psychosis or other extreme states. The Psychotherapy and Counselling Journal of Australia. 8(1), Available: http://pacja.org.au/?p=5394

The capacity to be empathic and communicate empathically are foundational skills of counselling and psychotherapy, if not all interpersonal helping endeavours. Empathy requires the capability, inclination and capacity to take the perspective of others, appraise and understand their experience without being overwhelmed, and communicate this understanding in a helpful way to the other person. This paper reviews and highlights the importance of this interpersonal capability and describes a form of ‘advanced empathy’ characterised by the capacity to take the perspective of others experiencing extreme states, making sense of this experience and conveying an understanding of that experience in a way which is useful to the person. The capacity for ‘advanced empathy’ is a foundation for any kind of therapeutic work with people who may express delusional or disturbing ideas and will be helpful for anyone needing to develop or maintain a relationship with people in extreme states. These ideas have been tested in practice and with a wide variety of audiences. This synthesis and summary might therefore be useful for training, supervision or reflection by those who hope to build alliances with people who may be in crisis, experience psychosis or are ‘out of step’ with people around them. This paper argues that empathy is useful in most helping relationships but is essential to effective mental health care.

Lakeman, R., & McIntosh, C. (2018). Perceived confidence, competence and training in evidence-based treatments for eating disorders: a survey of clinicians in an Australian regional health service. Australasian Psychiatry, 26(4), 432-436. doi:10.1177/1039856218766124

Objectives: Eating disorders are challenging to treat and contribute to considerable morbidity and mortality. This study sought to identify the educational preparedness, competence and confidence of clinicians to work with people with eating disorders; and to identify how services might be improved.
Method: Clinicians who worked in the emergency department, medical, paediatric wards and mental health services were invited to complete an online survey.
Results: One hundred and thirty-six surveys were returned. Seventy three percent of respondents reported little or no confidence working with eating disorders. There was a strong linear correlation between perceived confidence and competence and hours of education. Those with 70 or more hours of self-reported training were 2.7 times more likely to rate themselves as both confident and competent. Improving services for people with eating disorders included the provision of appropriate training, improving access to services including psychotherapy, and facilitating consistency in and continuity of care.
Conclusions: To increase the confidence and competence of the workforce, regular training around eating disorders should be undertaken. The establishment of a specialist team to provide services across the continuum of care for people with severe or complex eating disorders appears warranted in a regional health service.

Lakeman, R., & Emeleus,M. (2014) Un-diagnosing mental illness in the process of helping. Psychotherapy in Australia, 21(1), 38-45

A medical diagnosis of a mental illness is a powerful symbol of both the presumed nature of the person's experience and the authority of the person making the diagnosis. RICHARD LAKEMAN and MARY EMELEUS consider the meaning of diagnosis, its place in the ritual of health care, and the practical problems associated with not diagnosing and un-diagnosing. The traditional approach of western medical practice is to undertake an assessment and arrive at the correct diagnosis, which in turn determines the right treatment. Service users present frequently to helping agencies with a diagnosis of mental illness conferred already. This colours the therapeutic encounter and raises expectations of what needs to be done. The therapeutic potential and practical problems of deferring psychiatric diagnosis or 'un-diagnosing’ mental illness in the context of providing care to people with complex presentations is critically considered. Un-diagnosing mental illness can be an important part of the care encounter as a way of opening a space within which the person’s problems can be considered in a non-biomedical way, or in the final phase of the therapeutic encounter.

Lakeman, R. (2014). The Finnish open dialogue approach to crisis intervention in psychosis: A review. Psychotherapy in Australia, 20(3), 26-33

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.

Lakeman, R. (2014). Unknowing: A potential common factor in successful engagement and psychotherapy with people who have complex psychosocial needs. International Journal of Mental Health Nursing, 23(5), 383-388, DOI: 10.1111/inm.12067

Mental health nurses have a demonstrated capacity to work with people who have complex mental health and social problems in a respectful and non-coercive way for lengthy periods of time. Despite contributing to positive outcomes, nurses are rarely described as possessing psychotherapeutic skills or having advanced knowledge. More often, they are described as being instrumental to medicine, and nurses are socialized into not overstepping their subordinate position relative to medicine by claiming to know too much. Paradoxically, this position of unknowing, when employed mindfully, could be a critical ingredient in fostering therapeutic relationships with otherwise difficult to engage people. The concept of unknowing is explored with reference to different schools of psychotherapy. Adopting an unknowing stance, that is, not prematurely assuming to know what the person's problem is, nor the best way to help, might enable a deeper and more authentic understanding of the person’s experience to emerge over time.

Lakeman, R., Cashin, A., & Hurley, J. (2014). Values and valuing mental health nursing in primary care: what is wrong with the ‘before and on behalf of’ model? Journal of Psychiatric and Mental Health Nursing, 21(6), 526-535.

The Mental Health Nurse Incentive Programme (MHNIP) provides funding to organizations to enable mental health nurses (MHNs) to provide care to people with complex needs in primary care settings in Australia. The programme is based on a 'for and on-behalf of' practice nursing model whereby the MHN is presumed to have no specialist knowledge, skills or professional autonomy, and rather extends the reach of medicine. This paper provides a profile of MHNs working in the MHNIP derived from an online survey. A content analysis of responses establishes that nurses who work within MHNIP are highly experienced, and have extensive postgraduate qualifications particularly in psychotherapy. Nurses have negotiated a range of complex employment and contractual arrangements with organizations and pushed the boundaries of the programme to realize good outcomes. The 'practice nurse model’ of employment and the underpinning assumptions about MHNs and their skill set relative to other professions is critically examined. Changes to the programme funding mechanism and programme specifications are recommended.

Lakeman, R. (2006). Adapting Psychotherapy to Psychosis. Australian e-Journal for the Advancement of Mental Health, 5(1). URL: http://www.auseinet.com/journal/vol5iss1/lakeman.pdf

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

Lakeman, R. (2021). Mental health nurses locked out while Australia locks down. Journal of psychiatric and mental health nursing, 28(2), 299-299. https://doi.org/https://doi.org/10.1111/jpm.12638

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…

Hurley, J., Lakeman, R., Cashin, A., Ryan, T., & Muir-Cochrane, E. (2020). We are not quite ‘all in this together’: Mental Health Nurses struggle for equitable access to the Medicare Benefit Schedule (Letter). International journal of mental health nursing, 29(4), 745-746. Doi:10.1111/inm.12741

While the physical health challenges posed by COVID-19 are undoubtedly complex and for many tragic, the mental health repercussions will remain within our communities for years to come. Australia and Australian mental health nurses (MHNs) are regrettably well versed in responding to natural disasters. Devastating cyclones, bushfires, and droughts have all impacted our communities very recently. Mental health services often led by MHNs have responded to help communities and individuals adjust to the trauma and deep loss and to then go on and build resilience…

Lakeman (25-26 November, 2020). The case for equitable access to mental health nurse psychotherapists: improving access and outcomes across the mental health continuum. Paper Presented at the Informa Connect ‘Australian Healthcare Funding Summit. Virtual

  • The Medicare Benefit Scheme (MBS), ‘Better Access’ program which focuses on providing subsidized focused psychological strategies is out of reach for large sections of the population due to the overvaluing of this service by eligible providers who charge excessive ‘gap fees’. Mental health nurses (whilst eligible through PHN funded programmes to provide services for people with higher level needs or when people can’t afford ‘gap fees’) have been excluded from the MBS. Additionally, eligibility to provide ‘Better Access’ has become the de-facto benchmark to provide other MBS items (e.g. the recent eating disorder Item Numbers) and a criteria for employment in many services such as headspace.
  • Mental health nursing is one of the oldest regulated professions, most trusted, and with a strong history and tradition of providing psychotherapy to those with the most complex needs. Surveys of mental health nurse psychotherapists in Australia indicate that they are highly trained (generally with Masters level qualifications specifically in psychotherapy) and often have decades of experience providing psychotherapy to vulnerable groups.
  • The public have been unfairly excluded from being able to access a subsidized service from Mental Health Nurses who may be the most experienced and able providers; MHNs have been unfairly discriminated against in primary care by being unable to earn a living providing skilled services in competition with often less skilled yet subsidised practitioners.
  • Granting immediate eligibility to MHNs to claim the MBS will address a serious skills shortage in primary care across the continuum of stepped care without the need for any further investment in training or education of health professionals.

Lakeman, R., Emeleus, M., & Anderson, S. (2018, October 14-26). What makes a difference? Narratives of participation in a high fidelity DBT programme. Presented ACMHN's 44th International Mental Health Nursing Conference Mental Health is a Human Right. Pullman Cairns International, Cairns, Australia

Dialectical behavioural therapy (DBT) is an evidenced based programme of psychotherapy which has been demonstrated to be helpful for some people who manifest with a constellation of problems including suicidal and self‐destructive behaviour, difficulty managing emotions, impulses, maintaining relationships and an unstable self‐image. A high fidelity DBT programme has been run in Cairns for close to 10 years and has included a 20 week skills group programme, telephone coaching as needed, and weekly individual therapy for the duration of client's participation. Little is known about what programme elements are essential in making a difference to people.

Methodology and Methods: Consenting participants in the programme were interviewed near commencement, midway at the end and 3–6 months post completion of the programme. Mental health service use and emergency department use history was also obtained. In this paper a thematic analysis of the aggregated qualitative data is presented orientated to consideration about what was helpful over the course of the programme.

Results: A rich narrative from participants about what was helpful about being in the DBT programme will be presented as well as potential problematic dynamics between clinicians and participants

Outcomes/Significance/Implications for the Profession: DBT is an exceptionally resource intensive and lengthy programme. Little is known about what the key ingredients are. These findings go some way to illuminating what makes a difference. DBT positively changes the discourse around the diagnosis of borderline personality disorder for all involved.

Translation to Policy and/or Practice Change: Recommendations will be made regarding governance of DBT programmes, length of programme, adapting core skills for the audience, matching clinicians to clients, dealing with alliance ruptures and adapting the programme to local circumstances.

Lakeman, R. (2016, 9-10 July). Every encounter can and ought to be a therapeutic encounter . Paper presented at the myPHN 2016: 'Connecting General Practice Conference'. Pullman Reef Hotel Casino: Cairns

People who live through or get over the most severe crises that push them to the brink of self-destruction often talk about decisive and pivotal points in their journeys which made a difference (Lakeman and Fitzgerald, 2008). People often describe experiencing a connection with another person or group in a different way to previous experiences or expectations. The nature and quality of the relationship can literally be 'the difference that makes a difference'. There is increasing acceptance that the quality of the therapeutic alliance is the largest factor associated with positive change in psychotherapy, eclipsing the specific technique employed or the training of the clinician; and some evidence that the therapeutic alliance is influential in all manner of medical outcomes. Those working at the coalface in primary care, emergency and welfare settings have the capacity to make life changing and sometimes lifesaving differences in the lives of people they encounter through their conversations and relationships. An often heard mantra is that primary care settings and practitioners are ideally placed to implement some intervention or another, conceived of by others. This presentation turns this notion on its head and proposes that general practice and primary care have a long history of therapeutic non-intervention; traditions of sitting with uncertainty and interacting in ways which assist people to live their lives as well as to address a specific health concern. It explores and in part celebrates how one can make a difference to people's mental health through sometimes brief conversational encounters with people in primary care. Lakeman, R., & Fitzgerald, M. (2008). How people live with or get over being suicidal: a review of qualitative studies. Journal of Advanced Nursing, 64(2), 114-126

Hurley, J., Lakeman, R. & Browne, G. (2014 Oct 7-9). Happiness and mental health nursing: growing our core identity. Paper presented at the 40th Annual Conference of the ACMHN: Honouring the Past, Shaping the Future. Sofitel Melbourne

The seminal work of Victor Frankel in forming Logotherapy and more recent studies exploring the construct of happiness suggest that individuals need a core purpose, so as to experience contentment and well-being. This paper applies this principle to the mental health nursing profession through proposing we have been distracted from our core purpose for half a century; most often by the sparkling lure of inflated promises by pharmaceuticals. Arguably, our hegemonic relationships with other disciplines also results in MHNs responding to the purposes and philosophies of the medical and psychology disciplines, resulting in a professional depression and stagnation of growth. Additionally, roles associated with custodial care further erode the humanistic and caring drivers that initially led many to the profession.

Efforts to illuminate the contribution of MHNs have produced a plethora of consumer satisfaction and identity studies; mostly showing satisfied consumers. However, such studies capture 'what is' rather than 'what could be’ the core purpose of MHNs and are hence limiting. Forwarded is that for MHNs to recapture this purpose that they need to evolve the therapeutic relationship into a more substantial therapeutic alliance, with a deeper adoption of consumers’ views and formalised talk based intervention capabilities. Credentialed MHNs have demonstrated that they are amply qualified in providing evidence talk based treatments to those with the most complex problems. Furthermore, most have advanced training in one or more schools of psychotherapy. This future direction can return MHNs to their core purpose and possibly, professional happiness.

Lakeman, R. (2013, 16 March). The survey of MHNIP Nurses: Who are they, what do they do, and what have they achieved? Paper presented at the Primary Mental Health Care: Working Together for a Better Future, Rydges Lakeside, Canberra.

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.

Lakeman, R. (4-7 Oct 2011). Wounding Healing: Understanding the process of dealing with trauma and death in the helping professions. Paper presented at the "Swimming between the flags?" The Australian College of Mental health Nurses 37th International Mental Health Nursing Conference, Marriott resort, Surfers Paradise, Gold Coast.

Jung suggested that ones own suffering and vulnerability contribute to the capacity to heal others. However, sometimes service users are not healed but fail to improve, experience trauma and even die. Few events are more wounding for professionals than failing to protect a service user from preventable harm or failure to intervene to prevent death. The toll of vicarious and direct trauma can be immense and challenge the capacity of the helper to continue in a genuinely helping role. There are few markers or flags to help navigate the best course and the helper may find themselves 'all at sea' or a long way from safe shores. Drawing on the findings from a grounded theory study exploring how homeless sector workers deal with the deaths of service users, this presentation considers the issue of trauma and the processes by which would-be helpers might deal with death and trauma, acknowledge and treat their wounds and continue in helping roles.

Lakeman, R. (2007, 10-12 September). Ordinary psychotherapy with extraordinary experience (Workshop). Paper presented at the Thinking, Feeling, Being: Critical Perspectives and Creative Engagement in Psychosocial Health, Dublin City University, Ireland.

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.

Cutcliffe, J. R., Stevenson, C., & Lakeman, R. (2018). Oxymoronic or Synergistic: Deconstructing the Psychiatric and/or Mental Health Nurse. In J. C. Santos & J. R. Cutcliffe (Eds.), European Psychiatric/Mental Health Nursing in the 21st Century : A Person-Centred Evidence-Based Approach (pp. 13-27). Springer International Publishing. http://ebookcentral.proquest.com/lib/scu/detail.action?docID=5261365

With apologies to William Shakespeare and his classic work ‘Romeo and Juliet’, in answer to his question: ‘What’s in a name? That which we call a rose by any other name would smell as sweet’, we would respectfully disagree with the Bard and suggest: a great deal. At the most fundamental (literal) level, names are simply a collection of letters and/or symbols that identify a person or entity. However, the value and power of names have long been recognized and expressed throughout human history. Etymologists point out how people’s names were far from mere cosmetic or audible aesthetics; they symbolized and communicated specific meanings and messages. Similarly, philosophers engage in (for some semantic, for others substantive) discussions about names, characterizing them as, amongst others, descriptors and linguistic mechanisms for reference. As a result, whether for referential, descriptive purposes or symbolic, communication purposes, names it seems matter…

Lakeman, R. (2018). The Withdrawn or Recalcitrant Client. In J. C. Santos & J. R. Cutcliffe (Eds.), European Psychiatric/Mental Health Nursing in the 21st Century: A Person-Centred Evidence-Based Approach (pp. 479-492). Cham: Springer International Publishing.

There are few groups who raise the anxiety of health professionals more than those who don't improve as expected, who don’t follow recommendations or who fail to engage with them in a respectful or cooperative way. Main (1957, p. 129) suggested that the sufferer who frustrates a keen therapist by failing to improve is always in danger of meeting primitive human behaviour disguised as treatment. He observed that nurses would only give a sedative when they were unable to stand the patient’s problems without anxiety, impatience, guilt, anger or despair; whatever their justification for the treatment. Today the reluctant, recalcitrant or a-motivated service user is at risk of coercion and increasingly desperate and frequently non-evidence based treatment measures. An armoury of long acting 'depot’ medications, other dangerous medications and ECT may be imposed on individuals who fail to improve at the pace expected of them, often perpetuating a cycle of further resistance and reluctance to engage with the health care system…

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