Conference Presentations

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

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

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

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

This presentation will consider the current context of mental health nursing, and the challenges that lie ahead for the profession. It will critically consider what may be needed to enable practitioners to look back on their professional lives with pride and few regrets knowing that they have made a positive and lasting difference to the mental health of individuals, families and communities.

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

There are many words to describe the forms of distress and experience that are of interest to mental health professionals. Regardless of our native tongue we liberally draw upon a shared lexicon to describe disorders, services and treatments. However, a shared language does not mean a shared understanding. We have collectively constructed an elaborate fiction regarding mental illness and mental health service provision and this is serialised in our research reports, conferences and conversations. Words whether taken from our diagnostic manuals or applied as monikers to services we provide do not make immutable facts. We need to be mindful of the inter-subjectivity of all that we do and richly describe the context of our work rather than assume it is understood. Mental health care might best be understood as culture rather than science. Cultures are dynamic, social constructs and members of a culture are pre-disposed to cultural bias. Viewing mental health care from a cultural perspective can liberate practitioners and service user alike and provide a focus on developing cultures of care and healing.

Attempted suicide or perceived suicide risk is a common pathway to psychiatric care and completed suicide the worst possible outcome. Nurses have an exceptionally important role to help people resolve suicidal crisis. However, the evidence base derived from formal research to inform their work is fairly thin. This presentation uses suicide research to illustrate some of the problems associated with mental health research, translating findings into practice and measuring outcomes. Suicidal processes (like much of interest to mental health professionals) are complex bio-psycho-social phenomena not easily reduced for the purposes of research. Health professionals ought to be mindful of how exporting the products and tools of research into practice, shapes the way they see their work and the people whom they care for. As well as extending research to explore how people recover from a suicidal crisis this presentation argues that research is inherently limited in the extent which it can inform care of the suicidal person and other ways of knowing must be valued and cultivated.

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

Clinical supervision has established a long pedigree in the helping professions as a tool to assist people hone their practice, sharpen their skills, and endure the traumas associated with working with people in distress. It has provided a means by which the otherwise private exchanges between health professionals and recipients of care can be reflected upon, examined and improved. The seeds for clinical supervision were planted and germinated in another age in which face to face therapy developed well beyond the gaze of the public, and the knowledge of health practitioners and therapists were inaccessible to all but a few initiates. In a little over a decade, as a consequence of the evolution in digital technology, the ground has shifted. In 1964 McLuhan coined the phrase 'The medium is the message' and urged us to consider how we are shaped by the tools that we create. This paper reflects on the changes being wrought through evolving media on our notions of personal identity, community, helping professions and practices such as clinical supervision. If clinical supervision is to continue to bear fruit in the coming years then it will need to be a cultivar of the original variety, firmly rooted in concern for the intimate person-professional relationship but adapted to evolving media and shaped by the global context of professional practice.

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

Assertive Community Treatment (ACT) refers to a loosely related set of principles and practices focused on improving the lot of those identified as 'heavy service users', or those people who have historically been difficult to engage in treatment. A burgeoning body of research testifies to the effectiveness of ACT and a bewildering number of acronyms such as PACT, MIT, MCT, TCL and MST have been coined to describe services more or less faithful to ACT principles. This paper describes the key principles of ACT, research on outcomes and ACT programmes, presents a sketch of the Mobile Intensive Treatment Team in Townsville and critiques ACT from an ethical perspective. It proposes that ACT ought to commence from a philosophy of community mental health firmly grounded in respect for people, and ought to be the primary business of community mental health services.

Therapeutic programmes such as dialectical behaviour therapy (DBT) have traditionally included group skills training and individual therapy as face-to-face components. DBT is one of few psychotherapeutic programmes that is offered in State as well as private services, although accessibility to these programmes has often been determined by personal resources, and where one lives. COVID-19 forced an abrupt cessation to many programmes and then attempts to mirror face-to-face programmes using video conferencing. In this presentation, we report on a non-reactive adaptation to online DBT skills training that was developed before COVID-19 and employed a ‘flipped learning’ approach to DBT skills teaching. Seven therapists were interviewed with experience using a bespoke online platform to deliver DBT and monitor people’s progress. Whilst online engagement was not everyone’s first preference, it appears that it can greatly extend the reach of therapeutic programmes, is safe, and acceptable. Careful adaptation is needed to the online environment to make the most efficient use of both individual and group skills training.

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

The Productivity Commission and Victorian Royal Commission reports starkly outline the longstanding systemic flaws within Australian mental health services. These reports also signpost areas of opportunity for mental health nursing. These opportunities include positioning mental health nurses more prominently in community based services, delivering psychotherapeutic interventions and in early intervention roles. Additionally, opportunity exists in specific areas of need such as rural and regional workforce shortages. In short, within this era of potential reform we are almost uniquely positioned to be a major contributor, given the volume of our workforce and breadth of capability. However, those guiding policy and funding responses for reform remain mostly oblivious to our capabilities, despite assertive efforts.
One key reason for this lack of recognition is that politicians and their supporting public servants have little understanding of what a mental health nurse does, who they are and most importantly what clinical outcomes they achieve. This paper offers an overview of recent and current research detailing precisely such understandings. Data presented will demonstrate that mental health nurses have a breadth and depth of clinical capabilities in pharmacology, psychotherapy and aggression management, as well as advocacy and physical health (Hurley & Lakeman, 2020). Themes from a recent scoping review of mental health clinical roles highlight the fusion of both technical and non-technical capabilities that the mental health nurse enacts within these roles. Finally, evidence on mental health nurses under stating and minimising the value of their work will also be presented (Lakeman & Hurley, 2020).
It is challenging to make others communicate our capability and hence contribution to reform agendas. However, we do have influence on how we articulate our craft to others and should do so more often, more assertively and with greater clarity.

Mental health service users frequently rate the communication of empathy as the most valued capability of mental health nurses. Empathy is the most researched component of the therapeutic alliance, which is the most robust predictor of good outcomes for service users. Mental health nurses engage with people in extreme states, challenging people’s capacity to respond with empathy. This masterclass explores the importance of empathy and how this communicative skill can be employed therapeutically when working with people experiencing extreme states, perceptual disturbances, or expressing delusional ideas.

University students routinely rate and comment on teachers and their courses via anonymous surveys. A recent survey of around 800 university teaching staff in Australia found that many had received vitriolic and defamatory personalised commentary and catastrophic ratings from students (Lakeman et al., 2021). The impacts are profound. This ‘feedback’ affects people’s security of tenure, promotional prospects, mental health, and well-being and impedes the recruitment and retention of the best teaching staff (Lakeman et al., 2022). The drive to ingratiate students and elicit positive ratings leads to competition rather than collegiality, lowers academic standards and devalues the qualities and critical faculties needed in the mental health workforce. This presentation shares some examples of anonymous student ‘feedback’ and perceived impacts. Urgent reforms are needed to elicit feedback and enable students to have a ‘voice’. Developing a competent, therapeutic mental health workforce requires focused and renewed efforts to inculcate all mental health professionals with the capacity and competency to give and receive critical, insightful, meaningful, respectful and civil feedback.

This very brief presentation argues that mental health services are permeated by outdated, unhelpful, pathologizing discourses which are antithetical to genuinely trauma informed care. These discourses support antiquated, and largely unhelp models of service delivery. What research on approaches to trauma informs us of is that the ‘treatment’ for trauma is not medicine, or medicines, more beds, assessment or diagnosis. The treatment beyond prevention is psychotherapy. So what would our service models look like if we shifted the discourse to a psychotherapeutic one? How would things look different if our purpose was reframed as determining the right psychotherapeutic approach, and delivering the right dose by the right person or team to the person or family in a timely manner?

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

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

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

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

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

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

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

This paper draws upon the philosophical stance of social constructionism to better understand how mental health nursing is presently conceived and to consider its future (if indeed there is one). We also ask whose voices are shaping the future and the discourses that are constructed around health and illness that inform the need for mental health nursing. We adopt a reflexivity to current premises about mental health nursing and search for generative new narratives that may build new futures for the profession, or alternatively make it unrecognizable as a meaningful discipline. Social constructionism places value upon the use of language; language does not mirror life (Gergen, 2015); rather it is the doing of life. Once we begin to articulate the current and future states of mental health nursing social constructionism argues that we engage in a discourse constructed by tradition and taken for granted values. Our language is not seen as an accurate reflection of our profession and neither is the language of one given rank over that of the other; indeed, multiple descriptions exist for any single phenomena, in this case mental health nursing. However, this multiplicity of descriptions of what is and what could be the future (if any) of mental health nursing generates problems in terms of being able to create shared truth, knowledge and meaning among one another, and to those outside of the profession. The generation of these shared understandings through language consequently assumes rules to apply to the use of words within the contexts in which they are uttered, and it is from within this context that the meaning is generated.

These rules of social constructionism as applied to building a future for the profession inform us that as we describe, or otherwise represent, we fashion our future and that reflections on our understandings are vital to our future well‐being. These rules ask us to consider what relational groups are having the dominant discussions about the future of mental health nursing and who is being silenced, if anyone.

Gergen, K. (2015). An invitation to social constructionism (3rd ed). Los Angles: Sage. International Journal of Mental Health Nursing (2018) 27(Suppl. s1), 3–55

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

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

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

A 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. 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. Too much focus on diagnosis may sometimes be an impediment to understanding the person, the nature of their problems and determining the best approach to care. Regardless of the validity or utility of diagnosis health care systems often require the rapid conferral of a diagnosis and help is often conditional on a diagnosis being given. Service users frequently present to helping agencies with a diagnosis of mental illness having already been conferred and this can colour the therapeutic encounter and raise expectations about what needs to be done. This paper discusses the therapeutic potential and practical problems of 'un-diagnosing’ mental illness in the context of providing care to people with complex presentations. It also illustrates how a process of developing a shared formulation can in itself be a therapeutic process. Rather than being the starting point for care and treatment, the process of developing a formulation is both the destination and journey.

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

This paper presents findings from an ethics approved phenomenological study exploring mental health nursing roles and capabilities under the Mental Health Nurse Incentive Program (MHNIP) in two regional centres. Findings will be used to generate critical discussion on profes- sional identity factors such as clinical autonomy, nursing capabilities and effective interventions for young people. Happell, Palmer, and Tennent (2010) identify that the MHNIP offers a greater range of service provi- sion than has been previously available. Indications are that nurses working within the MHNIP are in fact offering a range of interventions beyond what was initially envisioned through providing effective talk based interventions, rather than restricting their practice to more his- torical roles of risk assessment, mental state examination and generic support. Mental health nurses offer unique contributions to the delivery of talk based interventions (Hurley, 2009). Despite this, perceptions of some referrers toward mental health nurse capability and the funding rules under the MHNIP may be seen as barriers to nurses undertaking such formal talk based therapy roles. Findings show that organisations such as Headspace offer pathways to address these barriers and to entrench talk based therapy roles into wider understandings of mental health nurse identity, to the benefit of service users.

This paper presented an overview of the Mental Health Nurse Incentive programme from the perspective of a general practitioner and mental health nurse

For anyone in a helping role, there are few events more professionally wounding than the unexpected death of a service user. People who work with homeless service users are often exposed to the trauma and death of those whom they try to help and this can take a toll both professionally and personally. This presentation outlines findings from a grounded theory study which explored how people in the homeless sector make sense and move on from the death of a service user and ultimately maintain a positive view of their work. A brief video of workers talking about their experience was developed to assist workers in the field better prepare to deal with death. The stories of these workers will have resonance for anyone who encounters the death of service users in their professional lives. This presentation encompasses an outline of the theory, a screening of the video and a brief discussion of its evaluation.

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

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

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

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

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

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

Few groups experience such high levels of morbidity and mortality as the homeless. Those that work in the front-line delivering health, welfare and other services to homeless populations are likely to be confronted by the death of service users. Death may be intentioned (as in suicide), unintentional (as in accidental overdose), the end point of some pathological process (as in liver or renal failure), entirely unexpected, and often violent. Working with populations with such high risk profiles for sudden death and direct or vicarious exposure to such traumatic events taxes the coping resources of frontline staff. This presentation presents some preliminary findings from a grounded theory study which explored how front line staff cope or deal with sudden death of those whom they aim to help. Particular emphasis is given to social processes people engage in to deal with death and to how discourses around homelessness and addiction are drawn upon and reinforced through these processes.

Migration has been a ubiquitous feature of the Irish social and cultural experience for over 150 years. However, in recent years Ireland has become a destination of choice for migrants from the rest of the world. This has posed a challenge for Irish institutions and Irish society, but rarely has service development been informed by the perceptions, opinions and expertise of migrants themselves. This presentation 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. In this project members of new community groups in Dublin who were affiliated with Cairde undertook focus groups exploring their perceptions regarding mental health, mental ill-health and their experiences of mental health care provision. The findings strongly suggest that the way migrants are presently treated within health and social services is often detrimental to mental health. The findings highlight structural inequalities that some migrants face in relation to legal status, accessing educational, occupational opportunities, and social service eligibility.

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

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

Working with homeless people entails working on the margins of society. Workers are frequently exposed directly and vicariously to the many traumas, indignities and injustices that characterises the lives of homeless people. Workers are confronted by marginalised lives and also frequently the sudden deaths of service users. The marginalised positions of both homeless person and homeless sector worker is a complicating factor that colours the experience and challenges the capacity of the worker to make sense of the death, work through the trauma and frame the death and ongoing work in a positive way. This presentation derived from a grounded theory study of homeless sector workers and sudden death will explore how workers resolve the problem of framing death and moving on drawing particularly on the narratives of homeless sector workers themselves.

Objectives Research involving people who may be suicidal is fraught with ethical problems. There are few guidelines to assist researchers or review boards clarify and negotiate issues that may be specific to suicide research. This survey aim to describe these problems and how they might be resolved.
Design: Experienced researchers (identified via published research) and ethics committee members were invited to complete an on-line survey addressing the risks, benefits and ethical problems associated with suicide research.
Methods: Twenty eight researchers and 125 ethics committee members participated in the survey from Australia, New Zealand, Canada the United Kingdom and Ireland. Findings were aggregated into themes using an inductive form or content analysis.
Results: A range of ethical problems were anticipated and addressed by researchers. Concerns of ethics committees centred 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 with people who may be suicidal requires both procedures to protect participants, and consideration of ethics as an ongoing negotiated process.

Suicide is a pressing social concern but engaging with suicidal people in research is fraught with ethical difficulties. This paper presents the findings of a web based survey of experienced suicide researchers and human ethics committee members (from Ireland, the United Kingdom, Canada, Australia and New Zealand) on the ethical problems and ethical practice involved with working with people who may be suicidal. Ethical research involving suicidal people requires both procedures to protect participants, and consideration of ethics as an ongoing negotiated process. The findings provide salient pointers for researchers and practitioners to consider in their work with suicidal persons.

The user movement is commonly understood to have been formed during the 1960s. At the heart of the movement was human rights and the deinstitutionalisation of the so called 'mentally ill'. Like all social movements the mental health user movement has experienced various transformations over time. User involvement is now a relatively common occurrence in the drawing up of policy and legislative documents, in the planning and development of mental health services and research projects. These advances are primarily attributable to the user movement. Indeed, we now have service users asked to present at major mental health conferences, carrying out their own research projects and running their own services with some individuals reaching the dizzy heights of becoming authors of academic papers and books. The audience will be encouraged to reflect on the user movement, its legacy and transformative processes. The three presenters will be challenging participants to think critically about the current state of the user movement and 'what it has become’. For example, has user involvement become a means by which services control the social agenda originally set out by the user movement? Has a hierarchy of service users developed mirroring that which exists within mental health services? Consequently, has the social status and levels of freedom for those deemed mentally ill improved since the 1960s? The presenters will address these controversial issues. Debate and dialogue with the audience to critically examine this will follow.

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

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

This paper provides an overview of findings and musings on a project to increase the quality of family and carer participation in adult mental health services. Research findings that particularly highlight the views of service users and family members will be highlighted.

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

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

The National Standards for Mental Health Services (Commonwealth of Australia, 1996) mandate the participation of consumers and carers in the development and evaluation of mental health services, and as partners in the process of care planning and evaluation. Yet recent reports continue to highlight that family members and carer's feel excluded from mental health care (Mental Health Council of Australia, 2005. In late 2004 Townsville Institute of Mental Health introduced practice standards (TIMHS, 2004), or minimum expectations regarding communication and information sharing with family and carers as policy in adult in-patient and community services. This paper describes the promotion and evaluation of these standards and observations from consumers and carers about what is important to them in relation to participation. The adoption of practice standards appears to be a simple and cost effective means of enhancing mental health care.

Commonwealth of Australia (1996). National Standards for Mental Health Services, Canberra
Mental Health Council of Australia (2005). Not For Service: Experiences of Injustice and Despair in Mental Health Care in Australia, Canberra
TIMHS. (2004). Practice Standards for Family / Carer Participation. Retrieved 23/2, 2006, from http://www.health.qld.gov.au/townsville/Documents/IMHS/Practice_Standards.PDF, Townsville

Introduction This research project examines communication processes between clinical supervisors and supervisees who engage in an online supervisory relationship via the Internet. An international team of nine researchers, comprising professionals and academics from a wide range of disciplines, collaborated in developing a long term research study to: explore the experience of computer mediated clinical supervision; establish the extent to which online clinical supervision matches the expectations of supervisees and meet professional standards; describe differences between computer mediated clinical supervision and face-to-face clinical supervision; and evaluate how communication practices are adapted using different computer applications in the process of online clinical supervision.
Method This presentation will illustrate: the development of the diverse research team; development of an ethical research proposal via collaboration through listserv communication; development of the project website (www.online-supervision.net); promotion of the research website; participants registering and indicating their suitability for inclusion or exclusion through website submission form (and quality control/training of participants); development of disclaimers and informed consent content; and technological design for matching supervisees within peer groups or and/or matching supervisees with supervisors.
Results It is anticipated that from the 80+ mental health professionals who have registered an interest in participating as of January 2003, a significant number will go onto become research subjects, along with other recruits, to form small supervision groups and dyads. A five-phase design encompasses an initial phase of data collection to enable the team to match participants, followed by four follow-up phases at three-month intervals of web based questionnaire completion about their experience of online supervision for analysis. Results of phase one of the research project and subsequent matching of participants and their expectations about the online supervisory relationship are presented as the result of the methodological techniques demonstrated.

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

Clinical supervision has a long pedigree in the mental health professions as a face-to-face relationship purported to assist in the maintenance of standards and to enhance practice through educative and restorative functions. The growth of the Internet and computer mediated communication technologies challenges the traditional notion that the context of clinical supervision need be face-to-face or undertaken by a supervisor intimately acquainted with the local practice setting. Over the last decade some psychiatric nurses and other health professionals have claimed that they have developed sustaining professional and collegial relationships akin to supervision or have actually entered into formal supervisory relationships using Internet technologies.

In 2002 an international research team comprised of a diverse range of disciplines collaborated in developing a long term research study to: explore the experience of computer mediated clinical supervision; establish the extent to which online clinical supervision matches the expectations of supervisees and meets professional standards; describe differences between computer mediated clinical supervision and face-to-face clinical supervision; and evaluate how communication practices are adapted using different computer applications in the process of online clinical supervision. This paper presents snapshots of the journey of this research team, and something of the reality and possibilities of on-line supervision.

An exploration of some of the on-line resources available to the psychiatric nursing community.

A primary function of nursing has been described as the facilitation of the conditions necessary for growth and development. Some of these conditions are basic and common to all and helping agencies are charged with providing or assisting people to obtain them. This paper explores some of these conditions and how nursing is sometimes impeded from realising a truly helping function in North Queensland. Through the story of Phillip it will be illustrated how care that has the potential to be growth enhancing and proactive can become merely palliative and reactive in the face of rigid and inflexible bureaucratic processes. Phillip's experience of being 'helped’ and his often clear statements of need challenge policy makers and helping agencies to reappraise the meaning of 'success’ in caring for people with enduring problems of mental health in the community. Our collective aims should be to assist people to thrive, not merely survive.

The explosive growth of e-mail and other forms of Internet-based and computer-mediated communication (CMC) promises to have a dramatic impact on human relations, with implications for nurses and nursing as for any other section of society. If nursing is to benefit from changing communication modes, the experiences of nurses who have already adopted and adapted to using the evolving technologies must be explored. Both authors undertook research examining nurses' use of the Internet in the mid 1990s, which provided a 'snap shot’ and a baseline for examining future changes. This paper reports on the findings of research undertaken collaboratively in the late 1990s using surveys of psychiatric and general nursing e-mail list groups to explore changes which have taken place in nurses’ use of CMC. The responses, when compared with the earlier findings, reveal that a growing body of nurses have become more sophisticated in their use of CMC, and are producing resources on the Internet. More importantly, CMC is rapidly becoming an essential and integral part of the routine of many nurses and is resulting in changes in practice.

Launching the sub-branch web site

This paper uses Slade's (1976) explanatory model as a framework for explaining hallucinations and considering helping interventions, which may 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.

This paper examines the ethical implications of nurses as tools, that is nurses carrying out the delegated or instrumental work of others. It is proposed that nursings' instrumental relationship with medicine, has in some instances led to an ethos, or moral climate which legitimises excluding nurses and patients from moral decision making and silences the moral voice of nursing. Nursings' involvement with compulsory psychiatric treatment is examined as a particularly problematic area of practice in terms of the legal requirement to carry out "doctor's orders" and exclusion from dialogue about the terms of treatment. Treating nurses as mere tools is challenged as unethical and the facilitation of a new health care ethos founded on values of collaboration, relationship and inclusion is proposed as a moral imperative for ethical health care.

This presentation explores issues surrounding being a mental health professional with a mental illness. Whilst consumer groups are establishing a niche within psychiatric and mental health services, many professionals may rightly claim to "have a foot in both camps". This presentation aims to lay bare some of the attitudes, stereotypes and contradictions in belief which shape the reality of health professionals with mental illness. The presenter's revisit the notion of the 'wounded healer' and suggest that the degree to which health professionals 'take care' of themselves and own their own vulnerability (collectively and individually) has a direct bearing on the kind of care that they can provide to others. The presenters have made similar presentations in the past and share some of the questions, which have arisen in their own practice and in response to previous presentations about the position of, and response to mental health professionals who have experienced mental illness.

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

A review of helping interventions for nursing the person who hears voices.

An examination of data from a study on computer mediated communication by psychiatric and mental health nurses

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

Recently nurses around the country were called to contribute to a ministerial task force examining barriers which prevent registered nurses contributing to the realisation of a more responsive, innovative, effective, efficient, accessible and collaborative health service. 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.

One cannot begin to make sense of coping experience without an understanding of the person's social world and how this informs and interacts with perceptions, and the attribution of personal meaning to the experience. The 1990s have been called the 'decade of the brain’. Today a person’s experience can be manipulated in a myriad of ways through the use of pharmacological agents. Because it is possible to completely ameliorate voices does not mean that we should. More than ever we need to extend our understanding of the voice hearing experience and bridge social and clinical conceptions.

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.