Peer Reviewed Journal Articles

With links to publications where available.

Hurley, J., Lakeman, R., Moxham, L., Foster, K., Hazelton, M., & Happell, B. (2024). Under Prepared for Practice: A Qualitative Study of Mental Health Nurse Undergraduate Workforce Preparation in Australia. Issues in Mental Health Nursing, 1–7.

Internationally there are both current and looming mental health workforce shortages. Mental health nurses who have received specialist education are a vital component to respond to these challenges. Aim: This qualitative study aimed to better understand the efficacy and product quality of mental health nurse workforce preparation through pre-registration nurse education in Australia. Method: To meet this aim 19 educators representing 13 different universities were qualitatively interviewed. Results: Thematic analysis found four themes (1) Graduates are under-prepared for safe mental health nurse practice; (2) Essential mental health nurse capabilities are missing in graduates; (3) Barriers to graduate preparation, and (4) Negative impacts of inadequate graduate preparation. Discussion: Findings from this study suggest future workforce shortages would be best addressed through direct undergraduate entry for mental health nursing Implications for Practice: All nurse undergraduate training needs significantly enhanced mental health theory and placement within the course.

Daguman, Esario I., Hutchinson, M., & Lakeman, R. (2024) Uncovering Complexities in Reducing Aggression, Conflict and Restrictive Practices in Acute Mental Healthcare Settings: An Overview of Reviews. International Journal of Mental Health Nursing, n/a(n/a).

Aggression, conflict and restrictive practices present complexities in acute mental health services, as do implementing service changes to reduce them. Existing published literature needs to offer more high-level guidance on the effectiveness of these service changes and their associated implementation factors. As a result, an overview of systematic reviews was undertaken to identify (i) nonpharmacological interventions to reduce conflict, aggression and restrictive practices in acute mental health settings, and (ii) their effects across different clinical outcomes. A parallel re-extraction from primary studies was then utilised (iii) to identify factors influencing successful intervention implementation. Of 124 articles sourced from nine databases and registries, four reviews were retained for the final analysis, using the direction of effect and tabular and narrative summaries. These reviews included programmes or interventions focused on inpatient adolescent, adult and older adult populations. They reported on alternative containment strategies, risk assessments, Safewards, sensory rooms and equipment, Six Core Strategy–based interventions and staff training. The overview found that a combination of interventions intended to improve relationships and reduce interpersonal conflict may help reduce aggression, conflict and restrictive practices. At the same time, stand-alone staff training and sensory rooms and equipment may have mixed effects. The quality of the evidence linking these interventions to reductions in aggression, conflict and restrictive practices is limited. Successful implementation hinges on multiple factors: intervention characteristics, preparation and planning, evaluation and monitoring, outcome interpretation, stakeholder involvement/investment, staff-related factors and contextual factors. Any implementation initiative may benefit from using pragmatic and complexity-informed research methodologies, including integrating meaningful involvement with service users, peer workers and culturally diverse groups.

Zubrinich, A., de Jong, G., Salehi, N., & Lakeman, R. (2024). Perceived barriers and enablers to utilising the Australian National Disability Insurance Scheme for adults with an intellectual disability and their families: A scoping review. Journal of Applied Research in Intellectual Disabilities, 37(4), e13240.

The introduction of the National Disability Insurance Scheme (NDIS) in Australia in 2013 promised significant improvements in the lives of adults with intellectual disabilities. Although the scheme enables support, there are challenges associated with establishing eligibility and administering funds. This scoping review explored perceived barriers and enablers to effectively utilising the NDIS for adults with intellectual disabilities and their families.

A scoping review of the empirical literature on the NDIS and intellectual disabilities included nine studies in this review. These papers were subjected to thematic analysis and the findings were presented as a narrative synthesis.

The key themes identified were: (1) Limited understanding of the NDIS process; (2) Language use and capacity assumptions; (3) Unrealistic goals and progress, and difficulty utilising plans; (4) Expectations of families and associated workloads; (5) Opening up opportunities not previously available; (6) Knowledgeable planners who actively seek to involve adults and their families.

Although qualitative studies demonstrate that adults with an intellectual disability and their families are largely satisfied with the increased opportunities the NDIS has afforded them, there are various areas in which accessibility to services can be improved. In order for the NDIS to continue to improve, the results from this scoping review underline the need for adults with an intellectual disability and their support systems to have their voices heard and be utilised.

Kelly, K., Moloney, A., de Jong, G., & Lakeman, R. (2024). Healthcare Practitioners’ Perceptions of the Barriers to Prescribing or Promoting Exercise in the Treatment of People with Mental Illness: A Scoping Review. Health & Social Care in the Community, 2024, 8894586.

Contemporary healthcare for those experiencing mental illness requires healthcare practitioners (HCPs) to effectively incorporate the prescription of exercise in their treatment, in accordance with clinical guidelines. However, there has been a lack of effective implementation of such recommendations. The purpose of this review was to identify barriers to exercise prescription in the treatment of people diagnosed with mental illness as perceived by HCPs. APA PsycINFO, CINAHL, MEDLINE, and PubMed electronic databases were searched for relevant articles published in the period from January 2005 to September 2023. A total of 18 papers were included for thematic synthesis. Four key themes were identified across the qualitative (8), quantitative (6), and mixed method (4) papers, including a lack of knowledge and confidence of HCPs in prescribing exercise; role and responsibility; HCPs’ misconceptions of client barriers; and systemic issues impacting exercise prescription practices. A lack of knowledge or confidence was the most common barrier. Some HCPs indicated a desire to develop their skills in exercise prescription, while others indicated a preference for an exercise professional to take responsibility for this aspect of treatment. Systemic barriers were spread across a range of issues, with lack of time, excessive workload, and difficulties accessing qualified staff most commonly cited. This review provides further insight into the barriers to exercise prescription faced by HCPs and makes recommendations regarding how to address these barriers in order to better implement clinical guidelines and thus improve the quality of treatment provided to people diagnosed with a mental illness.

Happell, B., Gordon, S., Hurley, J., Foster, K., Hazelton, M., Lakeman, R., Moxham, L., & Warner, T. It takes it out of the textbook: Benefits of and barriers to expert by experience involvement in pre-registration mental health nursing education. Journal of psychiatric and mental health nursing, n/a(n/a).

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.

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.
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.
A descriptive qualitative study involving 19 nurse academics from 13 Australian universities, involved in pre-registration mental health nursing education. Data were analysed thematically.
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.
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.

Lakeman, R., Moloney, A., & Emeleus, M.(2024). A file audit of gym usage in an Australian private inpatient psychiatric hospital. Australasian Psychiatry, 32(1),74-78.

This study aimed to determine the extent to which people admitted to a private psychiatric inpatient unit access and utilise the gymnasium and individualised coaching with an exercise physiologist (EP).
An audit of the medical record of 100 consecutive discharges and 60 individuals referred to an EP during the audit period was undertaken. Selected demographic information, physical health status, psychiatric diagnosis and routinely collected outcome data were extracted from files.
Twenty-four percent of people discharged from the hospital had documentary evidence of having attended the gym. These people were noted to have used the gym regularly and had an exercise prescription documented on discharge. Those with substance use disorder were more likely to use the gym than those diagnosed with an affective disorder. There were no significant differences in outcomes between those who were noted to exercise and those who did not.
Those who may most benefit from coaching around exercise in the context of hospital admission are not presently the individuals most likely to be referred to an EP. Standardised procedures for assessment, referral, exercise prescription and ongoing monitoring of activity and outcomes are recommended across the care continuum.

Lakeman, R., Foster, K., Happell, B., Hazelton, M., Moxham, L. & Hurley, J. (2024) Informing the development of a fit-for-purpose mental health nursing curriculum: A survey of mental health nurse academics in Australia. International Journal of Mental Health Nursing, 33(1), 93–103. Available from:

Inadequate mental health nursing content in pre-registration nursing curricula has been the topic of debate and concern since the introduction of comprehensive nursing education in Australia. Government-initiated inquiries and the efforts of mental health professional organizations and leaders have not successfully addressed this problem. The aim of the current study was to garner the perspectives and experiences of mental health nurse academics regarding the adequacy of mental health content in producing graduates able to work effectively in mental health settings and identify barriers and enablers to implementing and sustaining sufficient mental health content in pre-registration programs. A survey was distributed to mental health academics in Australian universities offering pre-registration nursing degrees. In total, 44 complete responses were included in the analysis. The results demonstrated the following: Most participants considered the current mental health content, theory and clinical hours insufficient to prepare graduates for practice in mental health settings. They reported a scarcity of tenured mental health nurse academics to deliver content effectively. Most participants were dissatisfied with the comprehensive approach to nurse education and preferred a double degree (nursing and mental health nursing), or a direct entry mental health nursing program. These findings provide further evidence for the current crisis in mental health nursing education and highlight the need for urgent action. People accessing health services have the right to receive high-quality care from appropriately qualified nurses. The inadequacy of mental health content in these programs effectively denies vulnerable people the standard of care and treatment they should be entitled to.

Wilson, A., Hurley, J., Hutchinson, M. & Lakeman, R. (2023) In their own words: Mental health nurses' experiences of trauma-informed care in acute mental health settings or hospitals. International Journal of Mental Health Nursing, 00, 1–11. Available from:

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.

Lakeman, R., Happell, B., Hurley, J., & Sullivan, D. (2023). The Impact of an Online Post-Graduate Interdisciplinary Mental Health Programme on Graduates’ Confidence and Practice. Issues in Mental Health Nursing, 44(7), 585-590, DOI: 10.1080/01612840.2023.2224874

This study aimed to examine the experiences of graduates of online interdisciplinary postgraduate mental health programmes in Australia. The program was delivered in 6-week terms. Seven graduates from diverse backgrounds were interviewed about their experiences with the course and its impact on their practice, confidence, professional identity, views on mental health service users, and their motivation for additional learning. The interviews were recorded and transcribed and underwent thematic content analysis. The graduates reported an increase in confidence and knowledge after completing the course, which led to a change in their views and attitudes towards service users. They appreciated the examination of psychotherapies and motivational interviewing, and applied their newly acquired skills and knowledge in their practice. The course was found to have improved their clinical practice. This study highlights a departure from traditional pedagogical approaches in mental health skill acquisition, as the entire program was delivered online. There is a need for further research to determine who might benefit most from this mode of delivery and to verify the competencies acquired by graduates in real-world situations. Online mental health courses are a feasible option and have been positively received by graduates. To enable graduates to participate in transforming mental health services, systemic change and recognition of their capabilities, particularly those from non-traditional backgrounds, is required. The results of this study suggest the potential for online postgraduate programs to play a significant role in transforming mental health services.

Hutchinson, M., Coutts, R., Massey, D., Nasrawi, D., Fielden, J., Lee, M., & Lakeman, R. (2023). Student evaluation of teaching: reactions of Australian academics to anonymous non-constructive student commentary. Assessment & Evaluation in Higher Education, 1-11.

Within higher education student evaluations of teaching (SET) are used to inform evaluations of performance of courses and teachers. An anonymous online survey was constructed and implemented using Qualtrics. This study was situated within a more extensive study investigating the impact of narrative SET comments on teaching quality and the health and wellbeing of academic staff. This paper reports specifically on two open questions that were designed to elicit examples of non-constructive and offensive anonymous narrative feedback. Five themes were identified: allegations; insults; comments about appearance, attire and accent; projections and blame; and threats and punishment. These are represented in non-redacted form. Personally destructive, defamatory, abusive and hurtful comments were commonly reported. These kinds of comments may have adverse consequences for the well-being of teaching staff, could contribute to occupational stress and in some cases could be considered libellous. The high prevalence of offensive comments accessible to and shared by teachers may be a reflection of the anonymity afforded to respondents using internet surveys, resulting in de-individuation and enabling some respondents to give voice to ‘hate speech’ which has no place in evaluations of teaching.

Sullivan, D., Lakeman, R., Massey, D., Nasrawi, D., Tower, M., & Lee, M. (2023). Student motivations, perceptions and opinions of participating in student evaluation of teaching surveys: a scoping review. Assessment & Evaluation in Higher Education, 1-12.

Several times each year the teaching performance of academics at higher education institutions are evaluated through anonymous, online student evaluation of teaching (SET) surveys. Universities use SETs to inform decisions about staff promotion and tenure, but low student participation levels make the surveys impractical for this use. This scoping review aims to explore student motivations, perceptions and opinions of SET survey completion. Five EBSCO® databases were searched using key words. Thematic analysis of a meta-synthesis of qualitative findings derived from 21 papers identified five themes: (i) the value students’ place on SET, (ii) the knowledge that SET responses are acted upon to improve teaching, (iii) assurance of survey confidentiality and anonymity, (iv) incentives for completing SET, and (v) survey design and timing of survey release. Perceptions, knowledge and attitudes about the value of SET are essential factors in motivating students to engage and complete SETs, particularly if surveys are easy to interpret, time for completion is incentivised and responses are valued.

Clough, A.R., Evans, A., Graham, V., Catterall, J., Lakeman, R., Gilroy, J., Pratt, G., Petrucci, J., Orda, U., Sehdev, R., Thornton, N., Das, S., Yearsley, G. and Stone, R. (2023), Emergency examination authorities in Queensland, Australia. Emergency Medicine Australasia.

In Queensland, where a person experiences a major disturbance in their mental capacity, and is at risk of serious harm to self and others, an emergency examination authority (EEA) authorises Queensland Police Service (QPS) and Queensland Ambulance Service (QAS) to detain and transport the person to an ED. In the ED, further detention for up to 12 h is authorised to allow the examination to be completed. Little published information describes these critical patient encounters.
Queensland's Public Health Act (2005), amended in 2017, mandates the use of the approved EEA form. Data were extracted from a convenience sample of 942 EEAs including: (i) patient age, sex, address; (ii) free text descriptions by QPS and QAS officers of the person's behaviour and any serious risk of harm requiring urgent care; (iii) time examination period commenced; and (iv) outcome upon examination.
Of 942 EEA forms, 640 (68%) were retrieved at three ‘larger central’ hospitals and 302 (32%) at two ‘smaller regional’ hospitals in non-metropolitan Queensland. QPS initiated 342 (36%) and QAS 600 (64%) EEAs for 486 (52%) males, 453 (48%) females and two intersexes (<1%), aged from 9 to 85 years (median 29 years, 17% aged <18 years). EEAs commonly occurred on weekends (32%) and between 2300 and midnight (8%), characterised by ‘drug and/or alcohol issues’ (53%), ‘self-harm’ (40%), ‘patient aggression’ (25%) and multiple prior EEAs (23%). Although information was incomplete, most patients (78%, n = 419/534) required no inpatient admission.
EEAs furnish unique records for evaluating the impacts of Queensland's novel legislative reforms.

Wilson, A., Hurley, J., Hutchinson, M., & Lakeman, R. (2023). Trauma-informed care in acute mental health units through the lifeworld of mental health nurses: A phenomenological study. International Journal of Mental Health Nursing, 32(3), 829-838

Trauma-informed care has gained increasing popularity in mental health services over the past two decades. Mental health nurses remain one of the largest occupations employed in acute mental health settings and arguably have a critical role in supporting trauma-informed care in this environment. Despite this, there remains a limited understanding on how trauma-informed care is applied to the context of mental health nursing in the hospital environment. The aim of this study was to explore what it means for mental health nurses to provide trauma-informed care in the acute mental health setting. The study design was qualitative, using van Manen's (Researching lived experience: human science for an action sensitive pedagogy. State University of New York Press, 1990) approach to hermeneutic phenomenological inquiry. A total of 29 mental health nurses participated in this study. There were three overarching themes that emerged; these entail: embodied trauma-informed milieu, trauma-informed relationality and temporal dimensions of trauma-informed mental health nursing. The study found that for mental health nurses, there are elements of trauma-informed care that extend far beyond the routine application of the principles to nursing practice. For mental health nurses working in the acute setting, trauma-informed care may offer a restorative function in practice back to the core tenants of therapeutic interpersonal dynamics it was once based upon.

Chen, Y., Nasrawi, D., Lakeman, R., & Massey, D. (2023). Reflections on transitioning from senior nurses to novice nurse academics. Contemporary Nurse, 1-9.

The transition from practicing nurse to nurse academic can be stressful as novice nurse academics need to assume new roles and acquire new skills in addition to having demonstrated mastery over their field of clinical practice. In this reflection, the authors use Gibbs’ reflective cycle to reflect on the experience of transition from being senior nurses to novice nurse academics in the Australian university context. A description of the experience of transition is outlined alongside the feelings encountered. The positive and negative aspects of the experience are then evaluated and an analysis of the experience put forward with a conclusion related to the overall experience. An action plan for future practice is offered, which we hope will be of interest to anyone contemplating such a journey or supporting others in this process. The complex and challenging journey ahead for novice nurse academics is outlined, which offers opportunities for growth and development.

Lakeman, R., Foster, K., Hazelton, M., Roper, C., & Hurley, J. (2023). Helpful encounters with mental health nurses in Australia: A survey of service users and their supporters .Journal of psychiatric and mental health nursing, 30(3), 279-593,

Successive inquiries into mental health services in Australia have identified the need for major reform of services and proposed a return to direct-entry nursing training.
To identify what service users, family and supporters have found helpful in their encounters with nurses in mental health settings.
A survey of 95 service users and supporters rated the importance of the capabilities and competencies of nurses. They also shared examples of helpful encounters with nurses which were subject to thematic analysis.
The most highly rated competencies were around demonstrating caring, empathy and understanding, and responding effectively in crisis situations. Helpful encounters involved enacted values, highly skilful interpersonal and psychotherapeutic engagement and practices that were facilitative and supportive.
The process and content of pre-registration nursing training needs to refocus on the nurse meeting the needs of service users and supporters, rather than the instrumental needs of services today.
Implications for practice
Educational reform may be necessary but insufficient to address anticipated nursing workforce shortages. Policymakers and health service directors need to align services with mental health nursing values and promote practices aligned with what service users and their supporters report as helpful.

Hurley, J., Foster, K., Campbell, K., Edan, V., Hazelton, M., Kennedy, H., Roper, C., & Lakeman, R. (2023). Mental health nursing capability development: Perspectives of consumers and supporters. International Journal of Mental Health Nursing, 32(1), 172-185.

Mental health nursing requires a specialist range of capabilities and values. In Australian contexts, the preparation of nurses to work in mental health settings has attracted criticism from government reviews, academics, and graduate nurses. Insufficient mental health content and clinical placement experience in undergraduate nursing courses have been central to this criticism. The study aim was to identify the areas and modalities of capability development of graduate mental health nurses, from the perspectives of end point users. In order to meet the aim, a four-item cross-sectional online survey with three additional and open-ended questions was developed. The questions were co-designed with consumer academics and reviewed by consumer and carer organizations. The survey was widely distributed across Australian consumer and carer organizations, with 95 useable responses. Findings indicated strong support for lived experience being integrated into teaching teams for nurses, as well as support for undergraduate direct entry for mental health nursing. Themed content from open-ended responses reflected the survey outcomes as well as prioritizing skill development to support better therapeutic relating and nurse self-care. Key findings included strong support for greater lived experience input into mental health nurse education, specialist undergraduate preparation and a focus on developing relational capabilities in the mental health nurse workforce.

Lakeman, R., Coutts, R., Hutchinson, M., Massey, D., Nasrawi, D., Fielden, J., & Lee, M. (2023). Playing the SET game: how teachers view the impact of student evaluation on the experience of teaching and learning. Assessment & Evaluation in Higher Education, 48(6), 749-759.

Student evaluation of teaching (SET) has become a ubiquitous feature of higher education. The attainment and maintenance of positive SET is essential for most teaching staff to obtain and maintain tenure. It is not uncommon for teachers to receive offensive and non-constructive commentary unrelated to teaching quality. Regular exposure to SET contributes to stress and adversely impacts mental health and well-being. We surveyed Australian teaching academics in 2021, and in this paper, we explore the perceived impacts of SET on the teaching and learning experience, academic standards and quality. Many respondents perceived that SET contributes to an erosion of standards and inflation of grades. A thematic analysis of open-ended questions revealed potential mechanisms for these impacts. These include enabling a culture of incivility, elevating stress and anxiety in teaching staff, and pressure to change approaches to teaching and assessment to achieve the highest scores. Playing the SET game involves balancing a commitment to quality and standards with concessions to ensure optimal student satisfaction. Anonymous SET is overvalued, erodes standards and contributes to incivility. The process of SET needs urgent reform.

Grace, S., Bradbury, J., Lakeman, R., Craig, R., Morgan-Basnett, S., & Twohill, L. (2022). Scientist practitioners in complementary medicine practice: A case study in an N-of-1 trial. Complementary Therapies in Clinical Practice, 49,101651.v

• Health practitioners need ways to foster a scientist-practitioner approach to practice.
• N-of-1 trials align well with patient-centred complementary medicine practice.
• After participating in N-of-1 trials, naturopaths continued to engage with current literature.
• After participating in N-of-1 trials, naturopaths continued to used validated questionnaires.

Lakeman, R., Hurley, J., Campbell, K., Hererra, C., Leggett, A., Tranter, R., & King, P. (2022). High fidelity dialectical behaviour therapy online: Learning from experienced practitioners. International Journal of Mental Health Nursing, 31(6), 1405-1416.

Dialectical behaviour therapy (DBT) is an effective treatment for borderline personality disorder and other problems underpinned by difficulties with emotional regulation. The main components of DBT are skills training groups and individual therapy. The COVID-19 outbreak forced a rapid adaptation to online delivery, which largely mirrored face-to-face programmes using videoconferencing technology. This study aimed to elicit and describe the experiences and learning of therapists involved in providing high-fidelity DBT programmes via the Australian DBT Institute, which established an online delivery platform called DBT AssistTM prior to the COVID-19 pandemic. The report conforms with the consolidated criteria for reporting qualitative research (COREQ). Seven therapists were interviewed. Data were transcribed and analysed thematically. Delivering skills training online, either exclusively or in hybrid form (with face-to-face individual therapy), was acceptable and even preferable to therapists and clients. It was considered safe, the programme was associated with few non-completers, and it improved the accessibility of DBT to those who might otherwise not be able to engage in a face-to-face programme. Skills training utilized a ‘flipped-learning’ approach which improved the efficiency of online delivery. Other unique and helpful features of the online programme were described. The best outcomes associated with online DBT are likely to be achieved through careful adaptation to the online environment in accord with the principles of DBT rather than mirroring face-to-face processes. Further research is required to determine the efficacy of online therapy relative to faceto-face, and who might be best suited to different modes of delivery.

Campbell, K., Massey, D., & Lakeman, R. (2022). Working with People Presenting with Symptoms of Borderline Personality Disorder: The Attitudes, Knowledge and Confidence of Mental Health Nurses in Crisis Response Roles in Australia. Issues in Mental Health Nursing 43(10), 913-922.

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.

Lakeman, R., Coutts, R., Hutchinson, M., Massey, D., Nasrawi, D., Fielden, J., & Lee, M. (2022). Stress, distress, disorder and coping: the impact of anonymous student evaluation of teaching on the health of higher education teachers. Assessment & Evaluation in Higher Education, 47(8), 1489-1500.

Anonymous student evaluation of teaching (SET) is a universal practice in higher education. We conducted a mixed-methods approach to investigate the nature and impact of anonymous SET commentary in the Australian higher education sector. Respondents shared a range of detailed SET exemplars, which revealed the extent of hurtful, defamatory and abusive commentary made by students. This paper reports the self-perceived impact of these on the health and wellbeing of academics. The majority of respondents reported that anonymous narrative comments contributed to workplace stress. There were no significant differences for gender. Younger academics were more likely to report the process of SET as stressful. Four themes were identified from the narrative responses: stress, distress, disorder and coping. These themes highlight the mental distress and impacts on well-being from repeated exposure to uncivil commentary made in SET by students. This distress was exacerbated by the failure of many employing universities to take substantial action to remedy or limit exposure to uncivil behaviour. The current system of anonymous SET has little validity and instead may operate as a vehicle for unfettered incivility directed towards teaching staff. The mental health impacts are significant for some and may impact the recruitment, retention and renewal of academic teaching staff into the future.

Hurley, J., Lakeman, R., Linsley, P., Ramsay, M., & Mckenna-Lawson, S. (2022). Utilizing the mental health nursing workforce: A scoping review of mental health nursing clinical roles and identities. International Journal of Mental Health Nursing, 31(4), 796-822.

Despite rising international needs for mental health practitioners, the mental health nursing workforce is underutilized. This is in part due to limited understandings of their roles, identities, and capabilities. This paper aimed to collate and synthesize published research on the clinical roles of mental health nurses in order to systematically clarify their professional identity and potential. We searched for eligible studies, published between 2001 and 2021, in five electronic databases. Abstracts of retrieved studies were independently screened against exclusion and inclusion criteria (primarily that studies reported on the outcomes associated with mental health nursing roles). Decisions of whether to include studies were through researcher consensus guided by the criteria. The search yielded 324 records, of which 47 were included. Retained papers primarily focused on three themes related to mental health nursing clinical roles and capabilities. Technical roles included those associated with psychotherapy, consumer safety, and diagnosis. Non-technical roles and capabilities were also described. These included emotional intelligence, advanced communication, and reduction of power differentials. Thirdly, the retained papers reported the generative contexts that influenced clinical roles. These included prolonged proximity with consumers with tensions between therapeutic and custodial roles. The results of this scoping review suggest the mental health nurses (MHNs) have a wide scope of technical skills which they employ in clinical practice. These roles are informed by a distinctive cluster of non-technical capabilities to promote the well-being of service users. They are an adaptable and underutilized component of the mental health workforce in a context of escalating unmet needs for expert mental health care.

Lakeman, R., King, P., Hurley, J., Tranter, R., Leggett, A., Campbell, K., & Herrera, C. (2022). Towards online delivery of Dialectical Behaviour Therapy: A scoping review. International Journal of Mental Health Nursing, 31(4), 843-856.

Dialectical Behaviour Therapy (DBT) programmes are often the only available treatment for people diagnosed with borderline personality disorder and were rapidly converted to online delivery during the COVID-19 pandemic. Limited research exists surrounding how the major elements of DBT are delivered in an online environment. This scoping review considered the operationalization of online delivery of DBT and its effectiveness. EBSCO host databases were searched using free text. Of 127 papers, 11 studies from 2010 to 2021 investigating online DBT for any clinical population were included in the review. A narrative synthesis of papers selected was undertaken. Seven articles reported results from five clinical trials (n = 437). Most adaptations mirrored face-to-face programmes although there was considerable variation in how therapy was facilitated. Attendance was reported to be greater online with comparable clinical improvements to face-to-face for those who remained in therapy. Additional challenges included managing risk, therapist preparedness and technology difficulties. Online delivery of DBT programmes is feasible and may be more accessible, acceptable and as safe and effective as face-to-face delivery. However, mirroring face to face delivery in an online environment may not be the most effective and efficient way to adapt DBT to online provision. Research is needed to identify areas which require further adaptation.

Clough, A.R., Evans, A., Grant, K., Graham, V., Catterall, J., Lakeman, R., Gilroy, J., Pratt, G., Petrucci, J. and Stone, R. (2022). Recent amendments to Queensland legislation make mental health presentations to hospital emergency departments more difficult to scrutinise. Emergency Medicine Australasia. 34(1), 130-133.

The Queensland Police Service (QPS) and Queensland Ambulance Service may detain and transport persons experiencing major disturbances in their mental capacity to an ED for urgent care. Queensland's new mental health legislation (March 2017) makes this legal intervention difficult to scrutinise. For a large non-metropolitan region, QPS records for emergency examination orders (EEOs) and emergency examination authorities (EEAs) were compared with annual reports of Queensland's Director of Mental Health and Chief Psychiatrist. From 2009–2010 to March 2017, QPS-registered EEOs totalled 12 903 while annual reports attributed 9441 to QPS (27% fewer). From March 2017 to 2019–2020, QPS-registered EEAs totalled 6887. Annual reports declared 1803 EEAs in total for this period, without distinguishing those registered by QPS from the Queensland Ambulance Service. Past year proportions of EEOs, however, indicate perhaps ~1100 originated with QPS (84% fewer). Information crucial for considered emergency mental healthcare responses for thousands of people is no longer readily available.

McCarrick, C., Irving, K., & Lakeman, R. (2022). Nursing people diagnosed with Borderline Personality Disorder: ‘We all need to be on the same hymn sheet’. International Journal of Mental Health Nursing, 31(1), 83-90.

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.

Lee, M., Coutts, R., Fielden, J., Hutchinson, M., Lakeman, R., Mathisen, B., Nasrawi, D., & Phillips, N. (2021). Occupational stress in University academics in Australia and New Zealand. Journal of Higher Education Policy and Management, 44(1), 57-71.

Occupational stress has increased in higher education academic staff over several decades, and this has been particularly acute in Australia and New Zealand. This scoping review sought to understand the causes and impacts of occupational stress among Australian and New Zealand academics. Eight EBSCO databases were searched for key terms: academic and occupational stress and Australia and New Zealand. Twenty relevant papers were sourced, from which five common themes were extracted: (i) balancing an academic workload, (ii) casualisation of the workforce, (iii) the managerialism phenomenon, (iv) transition from field of practice to academia, and (v) academic and other staff. Further research in the Australian and New Zealand context is required to identify the nature of specific stressors and how these impact health and well-being.

Lakeman, R., Coutts, R., Hutchinson, M., Lee, M., Massey, D., Nasrawi, D., & Fielden, J. (2021). Appearance, insults, allegations, blame and threats: an analysis of anonymous non-constructive student evaluation of teaching in Australia. Assessment & Evaluation in Higher Education, 1-14.

Within higher education student evaluations of teaching (SET) are used to inform evaluations of performance of courses and teachers. An anonymous online survey was constructed and implemented using Qualtrics. This study was situated within a more extensive study investigating the impact of narrative SET comments on teaching quality and the health and wellbeing of academic staff. This paper reports specifically on two open questions that were designed to elicit examples of non-constructive and offensive anonymous narrative feedback. Five themes were identified: allegations; insults; comments about appearance, attire and accent; projections and blame; and threats and punishment. These are represented in non-redacted form. Personally destructive, defamatory, abusive and hurtful comments were commonly reported. These kinds of comments may have adverse consequences for the well-being of teaching staff, could contribute to occupational stress and in some cases could be considered libellous. The high prevalence of offensive comments accessible to and shared by teachers may be a reflection of the anonymity afforded to respondents using internet surveys, resulting in de-individuation and enabling some respondents to give voice to ‘hate speech’ which has no place in evaluations of teaching.

Lakeman, R. (2021). ‘All animals are equal but some are more equal than others’: A discussion of guild capture of psychotherapy and the cost, Psychotherapy and Counselling Today. 3(1), p.24-28.

In 2021 the Australian Government announced the largest planned increase in investment in mental health services in the history of the Commonwealth. In the ‘Prevention, Compassion, Care’, National Mental Health and Suicide Prevention Plan (Commonwealth of Australia., 2021), ‘psychotherapy’ is not mentioned (or funded) at all (although ‘treatment’ is mentioned 14 times). Over half of committed expenditure is to extend existing initiatives in which the clinical work will primarily be provided through a small number of guilds at different rates of remuneration for the same work under the Medicare Benefits Schedule (MBS) scheme, Better Access. Meanwhile, the majority of Australians are unable to access a proper subsidised dose of the right therapy, at the right time from the most qualified person (often trained in psychotherapy). This paper discusses how professional guilds have appropriated ‘treatment’ as their own and how treatments provided by professional groups have become over-valued and unaffordable to those most in need. The call for action is for those most qualified to provide psychotherapy to clients most in need be enabled to access a subsidy through the MBS.

Gill, N. S., Parker, S., Amos, A., Lakeman, R., Emeleus, M., Brophy, L., & Kisely, S. (2021). Opening the doors: Critically examining the locked wards policy for public mental health inpatient units in Queensland Australia. Australian & New Zealand Journal of Psychiatry, 55(9), p. 844-848.

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.

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.

Hurley, J., & Lakeman, R. (2021). Making the case for clinical mental health nurses to break their silence on the healing they create: A critical discussion. International Journal of Mental Health Nursing, 30(2), 574-582.

This discursive paper aims to clarify what roles mental health nurses identify as being within their scope of practice in clinical settings. It also aims to highlight any consumer benefits arising from these roles. Role theory and its relationship with identity are critically discussed as a framework to explain how contemporary mental health nursing roles are poorly understood and undervalued within mental health services. In order to meet the aims of the paper literature written in the last five years by clinical mental health nurses reporting their roles, and outcomes of those roles were searched. This literature was then considered through the lens of social constructionism that premises truths are accessed and then constructed though relationship based language. Six core mental health nursing roles were identified across international settings. The MHN is a psychotherapist. The MHN is a consumer advocate. The MHN is a physical health therapist. The MHN is a psycho‐pharmacological therapist. The MHN is a relationship focussed therapist and finally the MHN is an aggression management therapist. While European and American nurses reported consumer benefit emerging from these roles those from Australia and the United Kingdom did not. The roles reported on were largely instrumental ones that offered little clarity towards the identity of our profession, nor its worth to consumers or funders of services. Mental health nurses will only have their true breadth of clinical capabilities recognized where there is a consistent construction emerging from clinicians in clinical settings on the efficacy of their clinical work.

Wilson, A., Hurley, J., Hutchinson, M., & Lakeman, R. (2021) ‘Can mental health nurses working in acute mental health units really be trauma-informed? An integrative review of the literature. Journal of Psychiatric and Mental Health Nursing, 28(5), 900-923.

Introduction: Trauma‐informed care (TIC) is an approach that mental health inpatient units are increasingly adopting, with mental health nurses (MHNs) being the largest occupational group working this area.
Aim: To critically examine the literature on TIC in mental health inpatient units from a MHN perspective.
Methods: Primary studies examining TIC in mental health inpatient units from a MHN perspective were examined in CINAHL, Medline and PsychINFO database including the reference lists of primary sources. A total of n=10 studies met the inclusion criteria with four themes identified.
Discussion: There is a paucity of quality research available on TIC to guide MHNs employed in mental health inpatient units. The review has highlighted that MHN practice is influenced by the medical model ideology and competing organisational demands that can at least partially negate the effective provision of TIC.
Implications for Practice: For purposeful application of TIC, the parallel and often unconscious organisational processes that exist for MHNs working in mental health units must too be examined.
Relevance Statement: The review invites an opportunity for important reflections by MHNs employed in mental health units. TIC may help restore MHN practice to the interpersonal tenants the profession is best distinguished by.

Campbell, K., & Lakeman, R. (2021). Borderline Personality Disorder: A Case for the Right Treatment, at the Right Dose, at the Right Time. Issues in Mental Health Nursing, 42(6), 608-613.

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. (2021). The Impact of Social Distancing on People with Borderline Personality Disorder: The Views of Dialectical Behavioural Therapists. Issues in Mental Health Nursing, 42(5), 410-416.

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. (2021). The role of mentalization in child psychotherapy, interpersonal trauma, and recovery: A scoping review. Psychotherapy. 58(1), 50-67.

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.

Lakeman, R., & Hurley, J. (2021). What mental health nurses have to say about themselves: A discourse analysis. International Journal of Mental Health Nursing, 30(1), 126-135.

Mental health nursing is largely invisible within public discourse. When mentioned at all in news media, it is usually a signifier of an occupation connoting where a nurse works. There is rarely a presumption of expertise in any sphere or articulation of a unique skill set ordefining features which differentiate the mental health nurse fro m other nurses. This paper sought to examine the professional discourse around mental health nursing as inferred from a review ofpapers published in the International Journal of Mental Health Nursing in 2019. A discourse analysis of full-text papers (n = 117) was undertaken exploring references to mental health nurses or nursing and what this communicated about the field. The discourse clustered around three themes: The invisible or absent mental health nurse, ambiguous and blended identities, and a group of low attributed value and sophistication. There were few examples of authors presenting mental health nurses in a way which counters stereotypes of the dominant discourse about mental health nurses as a lesser skilled occupational group. Academics, editors, authors, and practitioners are urged to contribute to the construction of discourse around mental health nursing expertise which differentiates it from other branches of nursing and other distinctive disciplines.

Lakeman, R., Emeleus, M., Davies, S., & Anderson, S. (2021) A pragmatic evaluation of a high-fidelity Dialectical Behaviour Therapy programme for youth with borderline personality disorder, Advances in Mental Health. 19(2) 116-126.

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.

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:

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.

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.

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.

This paper reports the capabilities of mental health nurse (MHN) psychotherapists in Australia and their perceptions on how to best utilize their skills.
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.
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.
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.

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,

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.

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.

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.

Molloy, L., Walker, K., Lakeman, R., & Lees, D. (2019). Mental Health Nursing Practice and Indigenous Australians: A Multi-Sited Ethnography. Issues in Mental Health Nursing, 40(1), 21–27.

Criticism of public mental services provided to Indigenous Australians have persisted over the last two decades, despite several national reports and policies that have attempted to promote positive service change. Mental health nurses represent the largest professional group practising within these services. This paper reports on a multi-sited ethnography of mental health nursing practice as it relates to this group of mental health service users. It explores the beliefs and ideas that nurses identified about specialist mental health nursing practice and Indigenous Australians. The study found a disunited approach to practice during the fieldwork. Practice was expressed as a series of individual constructions built upon the nurses’ beliefs about Indigenous Australians and their experiences in practice with these peoples. The criticism of mental health services from Indigenous communities was understandable to the mental health nurses, but how they could address this through their individual practices was not always clear to them. The actions by public mental health services to improve cultural safety through generic training related to the broad area of Indigenous health and health service needs, does not appear to evolve into informed specialist mental health nursing practice for Indigenous Australian service users.

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:

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.

Molloy, L., Walker, K., Lakeman, R., & Lees, D. (2019). Encounters with difference: Mental health nurses and Indigenous Australian users of mental health services. International Journal of Mental Health Nursing, 28(4), 922-929.

This article presents findings from the multi‐sited ethnography of mental health nursing practice as it relates to the care of Indigenous users of public mental health services in Australia. It provides an analysis of mental health nurses beliefs and ideas about Aboriginal and Torres Strait Islander people encountered over the course of this research. The Indigenous service user was positioned as Other to the non‐Indigenous mental health nurse, and to non‐Indigenous service users. Cultural difference and the legacy of colonization, including its impact on the health of Aboriginal and Torres Strait Islander peoples, contributed to these beliefs of alterity. Despite emphasizing the differences with Aboriginal and Torres Strait Islander people in mental health services, nurses did not clearly relate this to Indigenous ways of understanding ill health. While cultural differences were recognized, what they meant for the nurses or their nursing practice was interpreted in different ways. In these circumstances, approaches towards care for Aboriginal and Torres Strait Islander people varied between nurses.

Lakeman, R. (2019). The Myth of the Well-Known Client. Issues in Mental Health Nursing, 40(2), 191-193.

A common idiomatic phrase in mental health care is 'well known' client, patient, or service user. This phrase is often followed by “to mental health services” or some such, suggesting that a “service” can really know anything. Notwithstanding mental health services, especially public ones are a repository for a lot of information, such as facts about people, their service use, diagnosis, notes and assessments of various kinds; this conglomeration of information is not knowing, any more than a library may be “knowing”. Knowing is a distinctly human activity. This paper will argue that this phrase is arrogant, a signifier of ignorance and ought to be relegated to history or back room banter with phrases like “frequent flyer”, “bed seeker” and other derogatory and objectifying language.

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.

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.

Molloy, L., Lakeman, R., Walker, K., & Lees, D. (2018). Lip service: Public mental health services and the care of Aboriginal and Torres Strait Islander peoples. International Journal of Mental Health Nursing, 27(3), 1118-1126.

The failure of public mental services in Australia to provide care deemed culturally safe for Aboriginal and Torres Strait Islander people has persisted despite several national reports and policies that have attempted to promote positive service change. Nurses represent the largest professional group practising within these services. This article reports on a multisited ethnography of mental health nursing practice as it relates to this group of mental health service users. It explores the beliefs and ideas that nurses identified about public mental health services and the services they provided to Aboriginal and Torres Strait Islander people. During the fieldwork, mental health nurses described the constricting effect of the biomedical paradigm of mental illness on their abilities to provide authentic holistic care focused on social and emotional well-being. Despite being the most numerous professional group in mental health services, the speciality of mental health nursing appears unable to change this situation and in many cases maintain this status quo to the potential detriment of their Aboriginal and Torres Strait Islander service users.

Lakeman, R., & Molloy, L. (2018). Rise of the zombie institution, the failure of mental health nursing leadership, and mental health nursing as a zombie category.International Journal of Mental Health Nursing, 27(3), 1009-1014.

In this paper, we propose that mental health nursing has become a zombie category, at least in the Australian context. Mental health nursing is a concept that has lost any real explanatory or conceptual power, yet nevertheless persists in public discourse and the collective imagination. In recent decades, powerful forces have contributed to the zombification of the mental health nursing workforce and the academy. An increase in medical hegemony, the ascendancy of allied health in mental health service provision, the need for uncritical and servile workers, protocol-driven work practices, and a failure of leadership to mobilize any substantial resistance to these trends have enabled the infection to spread. The recognition of zombification, active resistance against the forces that conspire to cause it, and the cultivation of genuine conscientious critical thought and debate offer the only hope of survival of mental health nursing as a thriving specialty.

Lakeman, R. (2017). Mandated locked wards and mental health nursing. ACMHN News, Summer 2017, 18-19.

A few years ago I re-discovered a collection of professional souvenirs in a tobacco tin – assorted nursing medals, identity badges and service keys for a psychiatric hospital I had worked at. An inquiry of mental health nurse colleagues found that many had also held onto the keys (some of which are pictured in figure one). According to the authoritative 'Hints for Probationers in Mental Hospitals' reprinted by Gladesville Hospital in 1944 amongst other sage advice was 'Never let a suicidal patient out of your sight … Never allow your key to go out of your own possession' and “Never fail to report immediately a lock out of order”. This enlightened document also exhorted nurses to never treat patients as one mass but to respect their individuality, to maintain optimism and to regard every patient as curable. The charge nurse was un-equivocally and uncontestably responsible for the maintenance of the therapeutic milieu of the ward whether locked or closed…

Molloy, L., Walker, K., & Lakeman, R. (2017). Shared worlds: multi-sited ethnography and nursing research. Nurse Researcher, 24(4), 22-26.

Background Ethnography, originally developed for the study of supposedly small-scale societies, is now faced with an increasingly mobile, changing and globalised world. Cultural identities can exist without reference to a specific location and extend beyond regional and national boundaries. It is therefore no longer imperative that the sole object of the ethnographer's practice should be a geographically bounded site.
Aim To present a critical methodological review of multi-sited ethnography.
Discussion Understanding that it can no longer be taken with any certainty that location alone determines culture, multi-sited ethnography provides a method of contextualising multi-sited social phenomena. The method enables researchers to examine social phenomena that are simultaneously produced in different locations. It has been used to undertake cultural analysis of diverse areas such as organ trafficking, global organisations, technologies and anorexia.
Conclusion The authors contend that multi-sited ethnography is particularly suited to nursing research as it provides researchers with an ethnographic method that is more relevant to the interconnected world of health and healthcare services.
Implications for practice Multi-sited ethnography provides nurse researchers with an approach to cultural analysis in areas such as the social determinants of health, healthcare services and the effects of health policies across multiple locations.

Lakeman (2016) Paradoxes of Personal Responsibility in Mental Health Care. Issues in Mental Health Nursing. 37(12), 929-933.

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.

Lakeman, R. (2016). Yet another meta-analysis on antidepressant treatments: They don't work for most youth either, Connection: Newsletter of the Australian Society for Psychological Medicine, 68, p.12-14

Recently a meta-analysis of the comparative efficacy and tolerability of antidepressants for major depressive disorder in young people (6-18 years) was published by Cipriani and colleagues (2016) in the Lancet (more on this later). The meta-analysis is at the pinnacle of the evidence based hierarchy for drug trials. However, metaanalyses on anti-depressantshave generated controversy like few other classes of drugs. There are decades of experience using drugs and thousands of randomised controlled trials which have been published in order to have drugs approved for use. The meta-analysis, or aggregation of published and unpublished trial data calls the conventional wisdom that 'anti-depressants' are really anti-depression into question…

Molloy, L., Lakeman, R., & Walker, K. (2016). 'More Satisfying Than Factory Work: An Analysis of Mental Health Nursing Using a Print Media Archive', Issues in Mental Health Nursing, 37, 550-555.

The move towards comprehensive nurse training in Australia thirty years ago continues to trouble many of its mental health nurses. It has been viewed as a failure by many and the profession has been judged by some commentators to have lost its preparedness for specialist care. Discourse put forward to support this negative evaluation usually centres on the recruitment of mental health nurses and a limited interest among student nurses to undertake mental health nursing because of their negative opinions towards it. Emerging from a larger ethnographic research project focused on mental health nursing practice in Australia, this article presents an analysis of the profession's current circumstances using historical print media. As we move further from the era of direct entry, specialist training, the article notes the development of assumptions within the profession. These include the idea that mental health nurses received better training in direct entry, specialist programs, and therefore were better prepared for their specialist roles. The article puts forward a critique that challenges this. The article argues the most profound change faced by the profession is the erosion of the mental health nursing identity in Australia. The loss of the stand-alone hospital system, direct entry specialist training, and specialist professional registration have left mental health nursing with a growing uncertainty about itself as the profession evolves into its (mostly) post-mental institution world. At a time when the specialty of mental health nursing is experiencing serious staff shortages throughout the developed world, the article points to the importance of using historical sources to contextualize our present circumstances.

Lakeman, R., & Cutcliffe, J. (2016). Diagnostic Sedition: Re-Considering the Ascension and Hegemony of Contemporary Psychiatric Diagnosis. Issues in Nursing, 37(2), 125-130.

Historically, the publication of each edition of the diagnostic and statistical manual (DSM) has been accompanied by controversy. The publication of the latest edition (the DSM-5) has led to unprecedented critical commentary from authoritative voices from within psychiatry. Whereas, critical comment by mental health nurses has been negligible. This paper attempts to address this imbalance. It explores the history of diagnosis in psychiatry and drawing on recent critical commentary, and the rejection of the DSM by the National Institute of Health in future research endeavours, argues that the DSM-5 represents the latest in a long line of failed attempts to develop a valid, coherent and unifying taxonomy of mental illness. The implications for mental health nursing are briefly explored.

Lakeman, R. (2015). In a Pharmaco-Centric Era, Mental Health Nursing is More Important Than Ever. ABC Religion and Ethics, 8 Oct 2015. Online:

The prevailing naive bio-pharmaco-centric approach to human distress has not been found to be helpful to most and often serves to obscure alternative ways of viewing and addressing problems.

Molloy, L., Walker, K., Lakeman, R., Skinner, I. (2015). Ethnonursing and the ethnographic approach in nursing, Nurse Researcher, 23(2), 17-21.

Aim: To present a critical methodological review of the ethnonursing research method.
Background: Ethnonursing was developed to underpin the study and practice of transcultural nursing and to promote 'culturally congruent' care. Ethnonursing claims to produce accurate knowledge about cultural groups to guide nursing care. The idea that the nurse researcher can objectively and transparently represent culture still permeates the ethnonursing method and shapes attempts to advance nursing knowledge and improve patient care through transcultural nursing.
Data sources: Relevant literature published between the 19th and 21st centuries.
Review methods: Literature review.
Discussion: Ethnography saw a 'golden age’ in the first half of the 20th century, but the foundations of traditional ethnographic knowledge are being increasingly questioned today.
Conclusion:The authors argue that ethnonursing has failed to respond to contemporary issues relevant to ethnographic knowledge and that there is a need to refresh the method. This will allow nurse researchers to move beyond hitherto unproblematic notions of objectivity to recognise the intrinsic relationship between the nurse researcher and the researched.
Implications for research/practice: A revised ethnonursing research method would enable nurse researchers to create reflexive interpretations of culture that identify and embody their cultural assumptions and prejudices.

Lakeman (2015). Stigma: the reporting of workplace violence and mental health nursing. Australian College of Mental Health Nurses New, June-August, 18-19.

In 2014 a story run in the AGE and by the ABC asserted that 'mental health nursing' is the 'most dangerous profession' in Victoria with one in three mental health nurses having been assaulted in the past year . Whilst violence against health professionals in the conduct of their work is a real problem that needs careful analysis and a considered response this reporting likely contributed to stigma of those with mental illness (who are more likely to be victims rather than perpetrators of violence) and mental health nurses (who are but a small number of nurses who work with people identified as mentally ill).

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.

Browne, G., Hurley, J., & Lakeman, R. (2014). Mental health nursing: what difference does it make? Journal of Psychiatric and Mental Health Nursing, 21(6), 558-563.

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?

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.

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. & Bradbury, J. (2014). Mental health nurses in primary care: quantitative outcomes of the Mental Health Nurse Incentive Program, Journal of Psychiatric and Mental Health Nursing, 21(4), 327-335.

The Mental Health Nurse Incentive Program (MHNIP) provides a funding mechanism for credentialed mental health nurses to work in primary care settings in Australia with people with complex and serious psychosocial and mental health problems. This project explored the extent to which the programme contributed to positive outcomes. Sixty-four service user profiles were provided by nurses working within the programme, including the Health of the Nation Outcome Scales (HoNOS), on admission and at the last review point. Mean total HoNOS scores on admission were higher than those typically seen on admission to inpatient care in Australia. Significant reductions in all problem areas except physical health problems were found at the last review point for this sample. These findings support the viewpoint that MHNIP is addressing the needs of people with the most complex needs in primary care and is achieving clinically significant outcomes.

Happell, B., Byrne, L., McAllister, M., Lampshire, D., Roper, C., Gaskin, C. J., Martin, G., Wynaden, D., McKenna, B., Lakeman, R., Platania-Phung, C. and Hamer, H. (2014). Consumer involvement in the tertiary-level education of mental health professionals: A systematic review. International Journal of Mental Health Nursing, 23(1), p.3-16.

A systematic review of the published work on consumer involvement in the education of health professionals was undertaken using the PRISMA guidelines. Searches of the CINAHL, MEDLINE, and PsychINFO electronic databases returned 487 records, and 20 met the inclusion criteria. Further papers were obtained through scanning the reference lists of those articles included from the initial published work search and contacting researchers in the field. Thirty papers (representing 28 studies) were included in this review. Findings from three studies indicate that consumer involvement in the education of mental health professionals is limited and variable across professions. Evaluations of consumer involvement in 16 courses suggest that students gain insight into consumers' perspectives of: (i) what life is like for people with mental illness; (ii) mental illness itself; (iii) the experiences of admission to, and treatment within, mental health services; and (iv) how these services could be improved. Some students and educators, however, raised numerous concerns about consumer involvement in education (e.g. whether consumers were pursuing their own agendas, whether consumers' views were representative). Evaluations of consumer involvement in education are limited in that their main focus is on the perceptions of students. The findings of this review suggest that public policy expectations regarding consumer involvement in mental health services appear to be slowly affecting the education of mental health professionals. Future research needs to focus on determining the effect of consumer involvement in education on the behaviours and attitudes of students in healthcare environments.

Hurley, J., Browne, G., Lakeman, R., Angking, D. and Cashin, A. (2014). Released potential: A qualitative study of the Mental Health Nurse Incentive Program in Australia. International Journal of Mental Health Nursing, 23(1), p. 17-23.

The Mental Health Nurse Incentive Program (MHNIP) is a Commonwealth Government funded scheme that supports people living with a mental illness. Despite its significance, the program has received little attention from researchers nor critical discussion within the published work. This paper first critically examines the MHNIP from the contexts of identities, autonomy, and capabilities of mental health nurses (MHN) and then reports on findings from a qualitative study that explored the experiences of staff working in the MHNIP. Key findings from this qualitative study include four main themes indicating that both the program and the nurses working within it are addressing the unmet needs of people living with a mental illness. They achieve these ends by adopting holistic and consumer-centred approaches and by providing a wide range of therapeutic interventions. As well, the MHN in this study valued the freedom and autonomy of their practice outside public health services and the respect received from colleagues working in other disciplines. Findings suggest that MHN within the study were experienced as having autonomous identities and roles that may be in contrast to the restrictive understandings of MHN capability within the program's funding rules.

Lakeman, R. (2013). Mental health nurses in primary care: Qualitative outcomes of the Mental Health Nurse Incentive Program. International Journal of Mental Health Nursing, 22(5), 391-398.

The Mental Health Nurse Incentive Program (MHNIP) is a government-funded programme, which, since 2007, has enabled mental health nurses to work in primary care settings in Australia in collaboration with general practitioners (GPs) or private psychiatrists. To date, small-scale qualitative studies have explored outcomes of the programme from the point of view of nurses, consumers, and the perceptions of GPs. This study reports on an on-line survey of credentialed mental health nurses perceptions of outcomes of the MHNIP. Two hundred and twenty five nurses who worked in MHNIP provided detailed narrative responses that were examined using thematic content analysis. The most commonly-cited outcomes were reductions in symptoms or improved coping, improved relationships, and enhanced community participation. Other reported outcomes included reduced hospitalization or use of state-funded mental health services, better use of health services, the continuation or establishment of meaningful occupation, improved physical health and medication management, less use of coercive interventions, and greater independence.

Sibitz, I., Provaznikovaa, K., Lippa, M., Lakeman, R., & Amering, M. (2013). The impact of recovery-oriented day clinic treatment on internalized stigma: Preliminary report, Psychiatry Research, 209(3),326-32.

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.

O'Brien, L., Lakeman, R., & O'Brien, A. (2013). Managing potential conflict of interest in journal article publication, International Journal of Mental Health Nursing, 22(4), 368-373.

The issue of potential conflict of interest and its risk to professional integrity in journal article publication has been strongly debated in medical circles. Most medical journals adhere to international requirements for disclosure of potential conflict of interest. The debate on this issue in nursing, and specifically mental health nursing, has been neither prolific nor strong, despite nursing's potential to influence particular viewpoints about treatment and indeed to prescribe particular treatments; and nursing being a target for pharmaceutical industry marketing. The purpose of this paper is to raise debate about potential conflict of interest in journal article publication and to make recommendations for the management of such potential for this journal.

Cutcliffe, J., Stevenson, C., & Lakeman, R. (2013). Oxymoronic or synergistic: Deconstructing the psychiatric and/or mental health nurse, International Journal of Mental Health Nursing, 22(2), 125-134.

Examination of the names used to signify a nurse who specializes in working with people with mental health problems indicates the absence of a shared nomenclature and the frequent conflation of the terms 'psychiatric' and 'mental health’. Informed by the work of Derrida (1978) and Saussure (1916–1983), the authors encourage the deconstruction of and problematization of these terms, and this shows that what nurses who work with people with so-called mental illness are called has depended on where they have worked, the vagaries of passing fashion, and public policy. Further, there are irreconcilable philosophical, theoretical, and clinical positions that prevent nurses from practicing simultaneously as 'psychiatric’ and 'mental health’ nurses. Related service user literature indicates that it is disingenuous to camouflage 'psychiatric’ services as 'mental health’ services, and as signifiers, signified, and signs, psychiatric and mental health nursing are sustained by political agendas, which do not necessarily prioritize the needs of the person with the illness. Clearly demarked and less disingenuous signs for both mental health and psychiatric care would not only be a more honest approach, but would also be in keeping with the service user literature that highlights the expectation that there are two signs (and thus two services): psychiatric and mental health services.

Lakeman, R. (2013) Talking science and wishing for miracles: Understanding cultures of mental health practice, International Journal of Mental Health Nursing, 22(2), 106-115.

Science can only offer a limited account of and prescription for mental health care. Yet the language of science and faith in the universal applicability of particular scientific methods to the craft of mental health care has come to permeate mental health practice communities. This paper argues that many beliefs held by mental health professionals might be considered to be based on faith rather than science. This paper proposes that culture provides a useful lens for understanding mental health services and these paradoxes. Clearly there is a grand mental health narrative or colonising influence of biological psychiatry that in various ways affects all mains stream mental health services. Local health services and professional communities might be considered sub-cultures. Understanding how mental health professions and practice are embedded in culture may be useful in considering how practice changes and why. Culture and caring practices are mutually embedded in localised sub-cultures. Therefore a rich description of context and history is necessary in publication, presentation or other communications to enable genuine understanding by a global audience. Viewing mental health practice in a cultural context highlights the importance of values and difference and encourages humility in the face of ambiguity.

Lakeman, R., McAndrew, S., MacGabhann, L., & Warne, T. (2013). ‘That was helpful … no one has talked to me about that before’: Research participation as a therapeutic activity. International Journal of Mental Health Nursing, 22(1), 76-84.

There is considerable interest in the various ethical problems associated with undertaking health and social science research. Participants in such research are often considered vulnerable because of their health status, social position or dependence on others for health and welfare services. Researchers and ethics committees pay scrupulous attention to the identification and amelioration of risks to participants. Rarely are the benefits to participants of engaging in research highlighted or drawn to the attention of potential participants. Such potential benefits need to be considered by researchers and reviewers when considering the balance of benefits and harms associated with research projects. This paper particularly considers the psychotherapeutic benefits of participation in research.

Lakeman, R., McGowan, P., MacGabhann, L., Parkinson, M., Redmond, M., Sibitz, I., Stevenson, C., & Walsh, J. (2012). A qualitative study exploring experiences of discrimination associated with mental-health problems in Ireland. Epidemiology and Psychiatric Sciences, 21(3), 271-279.

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.

Lakeman, R. (2012). What is Good Mental Health Nursing? A Survey of Irish Nurses. Archives of Psychiatric Nursing, 26(3), 225-231.

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

Hurley, J., & Lakeman, R. (2011) Becoming a Psychiatric/Mental Health Nurse in the UK: A Qualitative Study Exploring Processes of Identity Formation. Issues in Mental Health Nursing, 32(12), 745-751.

Identity studies are well established across the social science literature with mental health nursing beginning to offer evidenced insights into what may, or may not, constitute key identity performances. For mental health nursing these performances remain contested, both from within the profession and from international contexts that favour generic constructions of mental health. This paper offers findings from a qualitative study that focused upon the process of how mental health nursing identity development is influenced, rather than what that identity may or may not be. These findings highlight that mental health nurses (MHNs) not only form their identity around service user centred education and training, but that many also use the education as a means to leave the profession. Through highlighting the impact of informal education (i.e., through work), formal education, and training upon the formation of mental health nursing identity, nurses are potentially alerted to the importance of clinically focussed mental health being prominent within curricula, rewarding mental health nursing skills specialisation, and the importance of the role of the service user in mental health nurse education and, hence, identity formation. Read More:

Lakeman, R. (2011). How homeless sector workers deal with the death of service users: A grounded theory study. Death Studies, 35(10), 1-24.

Homeless sector workers often encounter the deaths of service users. A modified grounded theory methodology project was used to explore how workers make sense of, respond to, and cope with sudden death. In-depth interviews were undertaken with 16 paid homeless sector workers who had experienced the death of someone with whom they worked. Transcripts of interviews and field notes were analyzed using the constant comparative method and a theory that described the positive framing of death emerged. Dealing with death and trauma is not something that most workers expect when they begin work but exposure to the death of a service user heightens expectations that other service users may be harmed. How workers cope or positively frame death depends on several interlinked processes. These include how the death is encountered; how the worker and others mark the death; and the extent that the vulnerability of self, peers, and service users is recognised and responded to. Successfully framing death enables the worker to continue working in the sector whilst maintaining enthusiasm for the work and compassion for service users.

Lakeman, R. (2011). It's time to rethink our thinking about mental health problems. British Journal of Wellbeing, 2(5), 8-9.

This paper extends some ideas proposed in the previous editorial and encourages people to reject simplistic bio-genetic explanations for mental health problems and instead foster a scientist-practitioner approach to health care and a reinvigoration of the art of bio-psycho-social problem formulation.

Lakeman, R. (2011). Leave Your Dignity, Identity, and Day Clothes at the Door: The Persistence of Pyjama Therapy in an Age of Recovery and Evidence-Based Practice. Issues in Mental Health Nursing, 32(7), 479-482.

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.

Sibitz, I., Scheutz, A., Lakeman, R., Schrank, B., Schaffer, M., & Amering, M. (2011). Impact of coercive measures on life stories: qualitative study. The British Journal of Psychiatry, 199(3), 239-244.

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.

Lakeman, R., & Matthews, A. (2010). The views and experiences of members of new communities in Ireland: perspectives on mental health and well-being. Translocations: Migration and Social Change, 6(1),

Ireland has a long history of outward migration but in recent years Ireland has become a destination of choice for migrants from the rest of the world. This has posed a challenge to Irish institutions and Irish society. This paper reports on the findings from a community development project undertaken in partnership between Cairde (a non government resource and advocacy organisation for ethnic minority groups) and Dublin City University. Members of new community groups in Dublin who were affiliated with Cairde took part in focus groups exploring their perceptions regarding mental health, mental ill-health and their experiences of mental health care provision. Participants focused more on their everyday experiences affecting their health and well-being rather than presenting their difficulties from within an illness paradigm. Whilst most participants had experience of accessing health services they had little contact with specialist mental health services. So while the study was designed to focus on conceptions of mental health/ill-health and services, the findings highlight structural inequalities that some migrants face in relation to legal status, accessing educational, occupational opportunities, and social service eligibility; all aspects of their everyday lives that cause them distress and fear.

Lakeman, R. (2010). Mental health nursing is not for sale: rethinking nursing's relationship with the pharmaceutical industry. Journal of Psychiatric and Mental Health Nursing, 17(2), 172-177.

The relationship between nursing and the pharmaceutical industry is conflicted. The pharmaceutical industry holds commercial interests which are incompatible with the interests of nursing and service users. Nursing and nurses are courted by the industry, most obviously to influence prescribing practices but also to promote a world view that psychiatric drugs are essential, and to sanitise the image of the industry (which has recently been rocked by fresh accusations of unethical practice). Nursing's image, the public trust it enjoys and ultimately good relationships with service users stand to be tarnished unless nursing rethinks its relationship with the industry. Nursing ought to reposition (or restore its position) next to service users rather than next to the pharmaceutical industry.

This paper was peer reviewed and originally accepted for publication in Mental Health Practice. It was even advertised for publication. However, it was withdrawn by a new editor. A satisfactory explanation was not provided and despite a request for the grounds for this editorial decision to be shared with readership this was not provided either.

Cutcliffe, J., & Lakeman, R. (2010). Challenging Normative Orthodoxies in Depression: Huxley's Utopia or Dante's Inferno? Archives of Psychiatric Nursing, 24(2), 114-124.

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.

Lakeman, R. (2010). Mental health recovery competencies for mental health workers: A Delphi study. Journal of Mental Health, 19(1), 62-74.

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.

Lakeman, R. (2010). Maintaining wellbeing when a service user dies. The British Journal of Wellbeing, 1(2), 28-33.

People who work with the homeless are likely to be exposed to the trauma and death of services users. A theory of how workers deal with sudden death was developed through grounded theory analysis of in-depth interviews with people who had worked in the sector. Maintaining well-being involves positively framing the life and death of the service user and homeless sector work. This involves a number of related processes and factors, such as the nature of the encounter with death, responding to death emotionally and procedurally, and being involved in the marking of death and memorials of the person's life. Being able to recognise and respond to the vulnerability of self, peers and service users is also important. Successfully framing death enables workers to stay in the sector while maintaining their own wellbeing, enthusiasm for their work and compassion for users.

Lakeman, R. (2010). What can qualitative research tell us about helping a person who is suicidal? Nursing Times, 106(33), 23-26

This paper summarises the findings of a review and synthesis of qualitative research addressing how people live with or recover from being suicidal, focusing particularly on the implications for nurses in a range of practice settings. Most research relating to suicide has mostly assisted in identifying at-risk groups. Qualitative research can help in understanding the experience of the suicidal and the recovering individual. Despite different methodologies, sample groups and research questions some consistent findings emerge from this body of work which serve to highlight the pain, suffering and alienation attendant to the suicidal crisis. Qualitative research also reveals the importance of connection and engagement with people and the potential for nurses to make an important, even life saving difference to suicidal people through the way they relate to them.

Irving, K., & Lakeman, R. (2010). Reconciling mental health recovery with screening and early intervention in dementia care. International Journal of Mental Health Nursing, 19(6), 402-408.

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.

Lakeman, R., Watts, M., & Howell, M. (2010). Growing leaders in mental health recovery. British Journal of Wellbeing, 1(9), 7-9.

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.

Lakeman, R., & Cutcliffe, J. (2009). Misplaced epistemological certainty and pharmaco-centrism in mental health nursing. Journal of Psychiatric and Mental Health Nursing, 16(2), 199-205.

This paper examines a trend and bias in nursing to overstate the evidence in support of pharmacological treatments. Examples of uncritical and emphatic statements of fact are drawn from recently published literature. Treating theories of biological causation of mental illness as fact and overstating the efficacy of pharmacological treatment leads to a pharmaco-centric view of mental distress and practice. This view is unscientific, and can be potentially dangerous in that it may constrain nurses from seeking the most appropriate responses to address the complex needs of those in need of nursing care

Lakeman, R., & Fitzgerald, M. (2009). The ethics of suicide research: The views of ethics committee members. Crisis: The Journal of Crisis Intervention and Suicide Prevention, 30(1), 13-19.

Background. Good quality, ethically sound research is needed in order to better understand, appropriately respond to, and reduce the incidence of suicide. There is, however, a lack of clarity around the nature of ethical problems associated with suicide research and how to resolve them. This is a formidable challenge for ethics committee members in approving and monitoring research.
Aims. To describe the views that members of health research ethics committee hold regarding ethical problems and ethical practice in research involving people who are, or who have, been suicidal.
Methods. Ethics committee members were invited to complete an online survey addressing the risks, benefits, and ethical problems associated with suicide research. Findings were aggregated into themes using an inductive form of content analysis.
Results. Concerns of ethics committees centered on accessing the population, potential harm to participants or the researcher, researcher competency, maintaining confidentiality, providing support to participants, and responding sensitively to the needs of family.
Conclusions. Ethical research involving suicidal people requires both procedures to protect participants, and consideration of ethics as an ongoing negotiated process. The findings of this research provide a snapshot of views held by a number of ethics committee members.

Lakeman, R., & Fitzgerald, M. (2009). Ethical suicide research: A survey of researchers. International Journal of Mental Health Nursing, 18(1), 10-17.

Research is needed to better understand and respond effectively to people who are suicidal. Involving people who are suicidal in research poses some ethical and pragmatic problems. The ethical problems and difficulties in obtaining approval to involve people who are suicidal in research has contributed to the current paucity of research that explores the suicidal experience. To explore some of these problems, a web-based survey of suicide researchers was undertaken. Researchers identified from published reports were contacted by email and invited to participate in a web-based survey. Researchers were asked to describe any problems they encountered, how ethical problems were negotiated or resolved, and any advice received from human research ethics committees. The main problems identified were accessing the population, maintaining confidentiality, the extent of care owed by the researcher to participants, and the facilitation of support to participants. As with clinical practice, ethical research involving people who are suicidal involves a process of sensitive engagement, and careful consideration and remediation of risk.

Lakeman, R., & Glasgow, C. (2009). Introducing peer-group clinical supervision: An action research project. International Journal of Mental Health Nursing, 18(3), 204-210.

Clinical supervision (CS) has been found to be beneficial in the role development of nurses and can contribute to increased job satisfaction and reduced burnout. However, implementing CS can be resource intensive, and there are few accounts of it being implemented in developing countries. Ten psychiatric nurses in Trinidad engaged in an action research project over a 5-month period to develop, implement, and undertake an initial evaluation of a model of peer-group CS for use in routine practice. The participants were involved in undertaking peer-group CS and contributing to monthly focus groups to reflect on the practices and further refine the model. This inexpensive form of CS was perceived by participants to have positive effects on the way they viewed and practiced nursing. An outline of the model and initial evaluation is presented, but further research is necessary to establish the sustainability of the model in practice.

Lakeman, R. (2008). Practice standards to improve the quality of family and carer participation in adult mental health care: An overview and evaluation International Journal of Mental Health Nursing, 17(1), 44-56.

Mental health services are required to involve family, carers, and service users in the delivery and development of mental health services but how this can be done in routine practice is challenging. One potential solution is to prescribe practice standards or clear expectation relating to family involvement. This paper describes practice standards introduced to an adult mental health service and a study that aimed to evaluate the impact of the standards on practice. Hospital and community files were audited before and after the introduction of standards for evidence of participation and surveys of carers and consumers relating to the quality of participation were undertaken. Increases in documented carer participation were found, particularly in relation to treatment or care planning. The expressed needs relating to participation varied in hospital and community settings. The majority of carers and service users were satisfied with their level of participation. The introduction of practice standards is an acceptable, inexpensive, and feasible way of improving the quality of family and carer participation, but gains may be modest.

Lakeman, R. (2008). Family and carer participation in mental health care: perspectives of consumers and carers in hospital and home care settings. Journal of Psychiatric and Mental Health Nursing, 15(3), 203-211.

It is widely accepted that family and carer participation in adult mental health care is desirable. However, rarely is service development informed by representative opinions of both carers and service users. This study took place in the context of a larger project to introduce and evaluate practice standards relating to family participation. The aim of this paper is to explore the perceptions of service users and carers to carer participation in adult mental health services. One hundred and twenty-nine service users and 86 family members recruited via hospital and community settings completed a survey which addressed obstacles to family participation, perceived benefits of participation and areas for improvement. Many service users and family were entirely satisfied with existing levels of family participation. Different needs for information, support and the nature of participation in mental health care are highlighted in acute hospital and community settings. Across settings, the provision of support and accessing services were identified as the most useful aspects of family participation. Meaningful carer and family participation in mental health care should proceed from respectful connection with carers and be informed by need which will vary depending on setting and circumstances.

Lakeman, R. (2008). The medium, the message, and evidence based practice. Issues in Mental Health Nursing, 29(3), 319–327.

Marshal McLuhan, the media guru of the 1960s, famously observed 'we shape our tools, and thereafter our tools shape us' (McLuhan, 1994, p. ix).Tools influence the way we think and behave, “we become what we behold” (McLuhan, 1994, p. 19).We extend ourselves through the tools we use but inevitably we also lose something in the process. For example, the invention of the automobile has greatly extended our mobility but it has also changed village life and led to pollution. In medicine, an over-reliance on diagnostic tests has been blamed for a loss of basic clinical skills (Bordage, 1995) and in nursing, an overextension of the scientific may lead to a diminishment of the humanistic. This paper considers McLuhan's proposition that our tools shape us in relation to mental health care and the tools derived from evidence based practice (EBP).

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.

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.

Lakeman, R., Walsh, J., & McGowan, P. (2007). Service users, authority, power and protest: A call for renewed activism. Mental Health Practice, 11(4), 12-16.

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.

Lakeman, R. (2006). Adapting Psychotherapy to Psychosis. Australian e-Journal for the Advancement of Mental Health, 5(1)

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. (2006). An anxious profession in an age of fear. Journal of Psychiatric & mental Health Nursing, 13, 395–400.

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.

Lakeman, R. (2004). Standardized routine outcome measurement: Pot holes in the road to recovery. International Journal of Mental Health Nursing, 13, 210-215.

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.

Lakeman, R. (2001). Making sense of the voices. International Journal of Nursing Studies, 38(5), 523-531.

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.

Lakeman, R. (2000). Negotiating the ethical minefield of psychiatric nursing practice. Nursing Praxis in New Zealand, 16(3), 38-48.

Psychiatric nursing practice can be likened to an ethical minefield. Nurses are often in the middle of the minefield and are pushed and pulled by forces, which are sometimes beyond their control. This paper signposts some of the more problematic areas of practice so that nurses may be equipped with at least a broad over-view of the ethical terrain.

Lakeman, R. (2000). Charting the future today: psychiatric and mental health nurses in cyberspace. Australian and New Zealand Journal of Mental Health Nursing, 9(1), 42-50.

The development of the Internet is happening at a staggering pace and promises to have a dramatic impact on human relations. If nursing is to adapt to and benefit from these changes, consideration ought to be given to the experiences and opinions of nurses who have adapted to and use the technology. This paper provides an outline of the findings of an Email survey of psychiatric and mental health nurses who are experienced in using the Internet. Questions focused on what psychiatric and mental health nurses use the Internet for, how their use has changed, work-related benefits, and what impact they see the Internet having in the future.

Lakeman, R. (1999). Advanced nursing practice: Experience, education and something else. Nursing Praxis in New Zealand, 14(2), 4-12.

This paper provides some critical reflection on the development of the concept of 'advanced practice'. Whilst defining, credentialing and regulating advanced practice promises rich fruits for nursing, advancing nursing practice will be a consequence only if the right conditions are fostered for the development and provision of nursing expertise in practice. A conscious and collective effort must be made to ensure that nursing expertise of all nurses is recognised and developed. One process which has shown promise in psychiatric and mental health nursing is 'clinical supervision. Evolving nursing leadership roles and more education can only provide a partial solution to the problem of advancing practice.

Lakeman, R. (2000). Advanced nursing practice: experience, education and something else. Journal of Psychiatric and Mental Health Nursing, 7(1), 89-94.

This paper provides some critical reflection on the development of the concept of 'advanced practice'. Whilst defining, credentialing and regulating advanced practice promises rich fruits for nursing, advancing nursing practice will be a consequence only if the right conditions are fostered for the development and provision of nursing expertise in practice. A conscious and collective effort must be made to ensure that nursing expertise of all nurses is recognised and developed. One process which has shown promise in psychiatric and mental health nursing is 'clinical supervision. Evolving nursing leadership roles and more education can only provide a partial solution to the problem of advancing practice.

Lakeman, R. (1999). Remembering Hildegard Peplau. Vision, 5(8), 29-31.

On the 17th of March 1999, Hildegard Peplau died at the age of 89, ending a nursing career, which spanned over fifty years. Peplau is often recognised as the 'mother of psychiatric nursing' but her ideas have influenced all fields of nursing.

Lakeman, R. (1999). 'Growing old' versus declining miserably: Some facts about depression and the older adult. Vision, 5(9), 6-12.

The twentieth century has been described as the "age of melancholy" (Barker, 1992, p.24). Whilst first world countries such as New Zealand have enjoyed great improvements in life expectancy we have also become increasingly miserable. Epidemiological studies suggest a ten-fold increase in the prevalence of depression since the Second World War (Barker, 1992). The notion of 'growing' older, has for many people been replaced with a reality of hopelessness and despair. What is particularly frightening is that depression is perceived by many people (including health professionals), as a normal and expected part of ageing. This article aims to explore some of the myths and realities of depression so that health professionals might better recognise and assist the older person experiencing depression and facilitate "growth" in ageing.

Lakeman, R. (1998). Beyond glass houses in the desert: a case for a mental health 'care' system. Journal of Psychiatric and Mental Health Nursing, 5(4), 319-328.

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.

Lakeman, R. (1998). Removing the toll bridge to compulsory treatment. Kai Tiaki: Nursing New Zealand, 4(8), 17-19.

This paper suggests that one need look no further than New Zealand mental health legislation and the medical hegemony over the compulsory assessment and treatment process to uncover barriers to nursing actualising it's potential

Lakeman, R. (1997). Dangerousness & mental illness: The implications for nursing practice. Vision, 3(4), 10-14.

Labelling a person as dangerous to others involves a prediction that the individual is likely to cause harm to another. Research suggests that there is a relationship between mental illness and violence but is unclear whether it is a cause and effect relationship. Epidemiological research informs about who has been violent but lacks precision in defining who is dangerous. Biological, psychological, environmental and social-interactional factors may all contribute to violent behaviour. The strongest current predictors of violence at present are a history of violence, a history of substance abuse and a coercive interactional style. Violence may be used in a purposeful way. It may be learned, reinforced and provoked through individual and group interaction.

Lakeman, R. (1997). Using the internet for data collection in nursing research. Computers in Nursing, 15(5), 269-275.

This article examines how the Internet may be used as a tool for data collection in nursing research. An overview of the demographic composition of the Internet population is outlined and discussed as a constraint on the type of research that can be undertaken using the Internet. Methods of data collection such as e-mail and WWW questionnaires are discussed as well as the possibility of virtual focus groups. Some of the difficulties and advantages that may confront the researcher wishing to undertake research using the Internet are outlined.

Lakeman (1997) Dangerousness and mental illness: The research and implications for nursing practice. Vision, 3(4), 10-13

This short paper was delivered at the Hawke's Bay Nurses Forum, and latter published in the Journal, Vision (Volume 3, Issue 4, 1997, pp. 10-13)

Key Points:
* Labeling a person as dangerous to others involves a prediction that the individual is likely to cause harm to another.
* Research suggests that there is a relationship between mental illness and violence but is unclear whether it is a cause and effect relationship.
* Epidemiological research informs about who has been violent but lacks precision in defining who is dangerous.
* Biological, psychological, environmental and social-interactional factors may all contribute to violent behavior.
* The strongest current predictors of violence at present are a history of violence, a history of substance abuse and a coercive interactional style.
* Violence may be used in a purposeful way. It may be learned, reinforced and provoked through individual and group interaction.

Lakeman, R. (1996). The ethics of bathing. Kai Tiaki: Nursing New Zealand, 2(2), 13-15.

This paper discusses the ethics of bathing someone against their expressed will.

Lakeman, R. (1996). Psychiatric nursing. The Internet: facilitating an international nursing culture for psychiatric nurses. Computers in Nursing, 16(2), 87-9.

The Internet consists of some ten million computers networked together. It provides a means of human communication which transcends boundaries of language, race and sex, as well as providing people with access to an unimaginable quantity of information. This paper reports on a qualitative study undertaken to explore how psychiatric nurses experienced in the use of the Internet currently use and benefit from it, how they have learned to communicate on the Internet and how they see the Internet affecting psychiatric nursing culture. The research was undertaken using electronic mail to several nursing discussion groups. The responses were analysed and are discussed according to themes that were identified from the data in response to the questions posed. Selected responses are used to illustrate the themes. The Internet may be a useful tool in facilitating a global psychiatric nursing culture based on egalitarian principles and characterised by a sense of belonging and a shared vision. The realisation of this potential is contingent on psychiatric nurses being pro-active in the use of technology and will be constrained or empowered by the creativity and vision of those who use it.

Lakeman, R., Ryan, T., & Emeleus, M. (2023). It is not and never has been just about the drug: The need to emphasise psychotherapy in psychedelic-assisted psychotherapy. International Journal of Mental Health Nursing, 32(3), 945-946.

We wish to congratulate Crowe et al. (2023) on their recent publication exploring the experience of psilocy-bin treatment. This paper was published a week after the Australian Therapeutic Goods Administration (TGA, 2023) approved the prescription of psilocybin for treatment-resistant depression by authorised psychia-trists under strict controls, acknowledging that patients may be vulnerable during ‘psychedelic- assisted psycho-therapy’. In Australia, the practice of psychotherapy is unregulated, undervalued, rarely provided in any form in public mental health settings, and often conf lated with subsidized brief psychological therapies in primary care (Lakeman, 2021). The medically sanctioned therapeutic use of psychedelics and empathogens may well ref lect a paradigm shift in how pharmacological treatments are viewed, and perhaps more importantly cement the im-portance of psychotherapy in the process of treatment…

Lakeman, R. (2023), Not even “just a nurse”: Institutional invalidation of mental health nursing. International Journal of Mental Health Nursing, 32(3), 631-632.

Invalidation is the delegitimizing or dismissal of a person's thoughts, feelings, and experiences (Musser et al., 2018). It can take many forms, such as verbal abuse, dismissiveness, or even silence. Invalidation is a type of small “t” trauma that, over time, can impact a person's mental health and well-being, making them feel unsupported, unimportant, and alone. The experience of invalidation is one putative contributor to the development of borderline personality disorder and underpins problems with emotional regulation (Linehan, 1993). It can also lead to feelings of self-doubt and low self-esteem and can make it difficult for individuals to trust others orform healthy relationships. Understanding the biosocial model and how childhood invalidation, emotional sensitivity and environment interact leading to emotional dysregulation, can be liberating and life-changingfor many people affected and be a first step towards healing (Braden et al., 2020). So too, mental health nurses ought to be aware of the institutional invalidation of their occupation and the impacts on their mental health….

Vella, D., & Lakeman, R. (2022). Mental health nurses' voices to lead. May 12. ACMHN News.

In this special article celebrating International Nurses Day, we hear from ACMHN Board Directors Donna Hansen-Vella and Richard Lakeman about mental health nurse (MHN) leadership: what it looks like, why Australia needs it, and how to empower MHNs to lead more.

Lakeman, R., Massey, D., Nasrawi, D., Fielden, J., Lee., & Coutts, R. (2022). ‘Lose some weight’, ‘stupid old hag’: universities should no longer ask students for anonymous feedback on their teachers. The Conversation, January 10,

Student evaluations, in the form of anonymous online surveys, are ubiquitous in Australian universities. Most students in most courses are offered the opportunity to rate the “quality” of their teachers and the course they take.

The original intention of student surveys was to help improve the learning experience. But it’s now become much more. Student surveys are often the only measure of teaching quality (along with pass rates). For lecturers, positive ratings and comments are often required to ensure continued employment or promotion.

But these anonymous surveys have also become a platform for defamatory, racist, misogynistic and homophobic comments against staff.

Lakeman, R. (2021). Why a billion dollars won't buy Australia improved mental health, Hospital & Healthcare, Friday 16th July,

Despite good intentions, increased federal funding for mental health services is unlikely to have a great impact on mental health outcomes in Australia. Recently the National Mental Health and Suicide Prevention Plan was released with the announcement of $2.3 billion of extra funding, the largest single increase in mental health expenditure in the history of the Commonwealth and promoted as ‘transformative’.

However, at least half of the expenditure is devoted to extending existing programs, the clinical work of which is funded almost entirely via the Medical Benefits Schedule (MBS), and there is little evidence that this will enable people to receive the right treatment at the right time by the most qualified person, especially when that treatment is psychotherapy….

This was also reproduced at: Lakeman, R. (2021) Why a billion dollars won't buy Australia improved mental health, Health Times, 6th August,

Lee, M., Nawasrawi, D., Hutchinson, M., & Lakeman, R. (2021). Our uni teachers were already among the world’s most stressed. COVID and student feedback have just made things worse. The Conversation, July 19,

Australia’s higher education workforce has literally been decimated during the COVID-19 pandemic. Mass forced redundancies and non-renewal of casual contracts were highly stressful. And now some disciplines and academics who committed their lives to teaching feel publicly invalidated as unnecessary in the reconstruction of the sector to produce what the government deems to be “job-ready graduates”.

Our recent review finds academics in Australia and New Zealand were suffering high levels of occupational stress well before COVID-19. Recent upheavals only added to existing problems. This is likely to jeopardise recruitment and retention of staff even in the very areas, such as health, teaching and medicine, where the government expects high future demand…

Lakeman, R. (2021). Mental Health Nurses are still not 'all in this together', Hospital & Healthcare, Thursday 20th May,

The lack of recognition of the specialist skills of mental health nurses (MHNs) by the Australian Government in the Budget and the failure to address the mental health needs of the Australian population should be of great concern to nurses everywhere.

Lakeman, R. (2021). Preparing for the mental health storm, The Medical Republic, 21 January,

The truth is the mental health crisis from COVID-19 is only just beginning. We expect the impacts to be felt for some time into the future. The best thing we can do for the nation is to emphasize positive psychology to try addressing the challenges instead of forcing those seeking help into a narrowly focused, risk-obsessed biomedical funnel of care.

Lakeman, R. (2021). Mental health nurses locked out while Australia locks down. Journal of psychiatric and mental health nursing, 28(2), 299-299.

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.

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, R. (2020). Are health professionals getting too much screen time? Computer-driven care and its impacts on mental health practice (Editorial). Journal of Psychiatric and Mental Health Nursing, 27(2), 101-102.

Since the advent of television, there has been concern about how “screen time” might affect the developing brains of children and contribute to health problems. Interacting with a device will inevitably change the brain and “how much” is “too much” is a question that preoccupies parents, educators and health professionals (Dickson et al., 2018; Gillespie, 2019). I invite health professionals to turn their gaze towards the provision of mental health care and consider how engagement with information systems may be impacting on their own development, view of mental health service provision and relationships with service users. I will focus on the Australian experience which may provide salutary lessons for other countries whose health services are not as far along the journey of becoming paperless and protocol‐driven.

Lakeman, R. (2019). Additional training essential for mental health nursing: Opinion. Aged Care insite, October 28,

There is an accelerating need for a skilled mental health workforce in Australia given the growing recognition of mental illness. However, developing an informed, flexible and skilled nursing workforce in hospital, community mental health and non-traditional settings is a challenge. The critical ingredients appear to be a mix of supported practice, particularly in the transition from graduate nurse to specialist, relevant postgraduate education and clinical supervision.

Lakeman, R. (2019). Additional training essential for mental health nursing: opinion. Nursing Review, October 28. Online:

Since the loss of state registration and endorsement by nursing boards and councils, the only way to achieve recognition for mental health nurses is through the Australian College of Mental Health Nurses Credentialing program. To be eligible, registered nurses must have completed at least a postgraduate diploma in the specialty and met further practice and supervision requirements. Increasingly, these credentials are required for advancement for nurses in the mental health field – and rightly so. The public deserve to receive mental health nursing services from appropriately skilled people.

Lakeman, R. (2011). Drugs are not the only option [Editorial]. British Journal of Wellbeing, 2(4), 5.

Lakeman, R. (2010). Epistemic injustice and the mental health service user [Editorial]. International Journal of Mental Health Nursing, 19(3), 151-153.

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.

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