News

“Inner rooms, inner minds” is the latest exhibition from Nottingham-based artist Edwina Kung, shown at the Institute of mental Health from 13 December 2022 – 24 March 2023. As the event draws to a close, we asked Edwina about the relationship between her art and mental wellbeing.

Dr Hugh Middleton (Consultant Psychiatrist Nottinghamshire Healthcare NHS Trust and the University of Nottingham’s School of Sociology and Social Policy) writes on how research is identifying success stories and offering new strategies for collaboration: To précis, mental health professionals need to work together if they are to fulfil their potential and deliver the best possible patient care, a new report has revealed (ref. below).

Hospital soap operas, everyday experience and what we hear about the “state of the NHS” all draw attention to strife between those who “do” health care and those who manage them, so it is good to see publication of some fresh research that tries to rise above this. October 10^th saw publication of the final report from a three-year investigation of multi-disciplinary team working in mental health. Numerous investigators were involved, including Dr Hugh Middleton and other participating organisations (e.g. Nottinghamshire Healthcare NHS Trust).

Healthcare professionals must work together as effective teams if they are to provide the best possible patient care. This is important for mental health services where quality includes consistency and a reassuring sense of being known and understood. Providing these and at the same time working in shifts, so that the service is available beyond office hours, is difficult without great team processes.

Previous research shows that many multi-professional teams fail to perform to their full potential, as they are not clear about their objectives, disagree about goals, their leadership and how to work together; or they find themselves trying unsuccessfully to meet the conflicting demands of senior managers from different disciplines. The Healthcare Commission has discovered that as many as half of all NHS staff may work in dysfunctional teams, which can jeopardise patient care and undermine staff well-being.

The overall aim of this research was to explore such issues in more focused detail amongst teams providing NHS mental health services. A variety of settings were investigated. Service users, their families and friends, a range of mental health practitioners and service managers were all consulted in the course of developing a novel measure of community mental health team effectiveness. Some 1500 practitioners from 120 teams took part in a survey which estimated how effective such teams were, and reported upon what it was like to work in them.

There were strong associations between team effectiveness, measured on a scale which reflects service users’ views of good and bad practice, and the quality of team working. This was assessed using the Aston Team Performance Inventory, a well-established measure of team working. Particular success in providing good quality mental healthcare was found amongst teams that had a clear sense of purpose, welcomed participation in creative problem solving and were well led in a style that encouraged reflective practice.

Alongside this survey the investigators also observed a number of team meetings and interviewed 114 service staff, 31 service users and 13 users’ informal carers. This qualitative research enabled enquiry into the interactions that lie behind numbers derived from the survey. In terms of what matters to service users it revealed disparities between what they find important, such as relationship, flexibility, availability, consistency and understanding, and requirements of the organisational settings from which care is provided.

Of service users, in the words of one community mental health team manager:

“… they don’t really want to see the paperwork and they don’t really want to see the risk assessment, don’t really want to see the care plan, sometimes they’ll talk to us about the care plan but they don’t want copies of it … a care plan doesn’t mean anything to them in that sort of sense but I think we do keep trying to engage with them … “ In relation to creativity, in the words of a support worker:

“So there may be some patients who would really, really benefit from you say taking them for a day at the seaside, because that was what they remembered their parents doing for them when they were little and that would mean so much for them to do that. We obviously can’t do that, and time is probably our most valuable resource really” These are readily dismissed as intuitive and predictable findings. Perhaps unsurprisingly they relate good clinical mental health outcomes to team creativity, task focus, participation, supportive leadership and interest in true relationship. On the other hand they are also timely and novel. They identify clear relationships between organisational determinants of the practitioner’s context and well-being, and the outcome of their clinical activities. It will require further studies to establish whether such interactions are also present in healthcare settings that are possibly less dependent upon practitioners carrying out “emotional work”, but an element of that is present in all health care settings. What this research demonstrates is that the success with which “emotional work” is conducted, in part reflects the practitioner’s emotional well-being and that is in the hands of those who manage and commission health care. There are connections between the management of health services and the service user’s experience which are not simply reflections of business efficiency, but provide the creative commissioner or manager with more sophisticated opportunities to influence real outcomes.

Reference:  West M, Alimo-Metcalfe B, Dawson J, El Ansari W, Glasby J, Hardy G, et al. Effectiveness of Multi-Professional Team Working (MPTW) in Mental Health Care. Final report. NIHR Service Delivery and Organisation programme; 2012.

Recent conferences, Q&A of paper presentations, and even my NHS REC meeting have recently made me question the impact of social research within mental health and the ‘so what?’ factor of non-clinical studies.  We live and work in an evidence-based system whereby the expectation is that results are observable, measurable, quantifiable and replicable.  Hence studies that value the lived experience of participants, and look for meaning rather than outcomes, can struggle to maintain a sense of validity and reliability within mental health research.

However, there is much that value-based research can offer.  As Larsen (2007) points out, evidenced-based studies that examine therapeutic intervention has a propensity to create the “black box” effect.  The research may show whether outcomes have been achieved, but it cannot address exactly how they were met.  Furthermore, these studies cannot say why these outcomes matter and who they matter to.  This omission is fairly significant given the discrepancies between provider and patient expectations.  Gilburt, Rose and Slade (2008:8) argue that ‘[d]ivisions in the views of patients and professionals in terms of what variables and themes are important mean that the resulting studies may be a poor representation of the user perspective’. Furthermore, evidence-based research ignores personal agency and creativity as it requires that support be routinised according to a set of rational mechanisms that are universally applied (Haigh, 2005).  From this perspective, individuals need only respond to a prescribed agenda of recovery rather than find meaning from their own unique experiences (Rose, 1999).  Thus in order to avoid prioritising “what works” over “what matters” (Haigh, 2005), we need studies that emphasise participants’ experiences of mental health and the outcomes that are important to them.

But there is an even greater ‘so what?’ question that value-based researchers within mental health must address.  Even if we can convince our audiences that value-based research is meaningful and needed, what do we actually do with it?  The conclusion section of many journal articles advocating the prioritisation of participant experiences usually end by saying something along the lines of, “the evidence-base should be expanded”, and/or, “what matters to participants should inform clinical practice and guide policy making”.  Whilst I wholeheartedly agree, I also cannot help but notice that they do not offer any suggestions on how to do this.

Given the evidence-based system that relies on outcomes that are deemed to be achievable and measurable, the direct impact of value-based research is not always obvious.  However it is well worth considering the practical implications of how exploring participant perspectives and highlighting lived experiences can have a real-world impact within mental health.

Posted by:
Jenelle Clarke
ESRC PhD Student (Sociology)
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References:
Gilburt, H., Rose, D. and Slade, M. (2008) The Importance of relationships in mental health care: a qualitative study of service users’ experiences of psychiatric hospital admission in the UK. BMC Health Services Research 8(92).  Available online: http://www.biomedcentral.com/1472-6963/8/92.

Haigh, R. (2005) The Trouble with Modernisation: we need better relationships, not policies and procedures. Mental Health Review Journal 10(3): pp.3-7.

Larsen, J.A. (2007) Understanding a Complex Intervention: Person-centred ethnography in early psychosis. Journal of Mental Health 16(3): pp.333-345.

Rose, N. (1999) Governing the Soul: the shaping of the private self. London: Free Association Books.

Turner (2002) identifies that recovery has been described as an idea, a movement, a philosophy, a set of values, a policy mantra and also a doctrine for change.  It splits opinion between those who view it as simplistic and obvious and others who see its revolutionary and transformatory potential.  Although increasingly fashionable within current mental health policy and practice, there are precedents for recovery as far back as the seventeenth and eighteenth centuries.  For example Phillippe Pinel appointed ex-service users in a bid for a humane regime at Biceptre in Paris and William Tuke developed moral therapy and self management approaches at the York retreat (Scull, 1981).  However, the roots of recovery are most firmly established in movements of protest intended to improve conditions in asylums and to give equal rights to citizens with disabilities.  Judy Chamberlin articulates these rights based approach when she appeals for recognition of the skills and abilities of people with mental health problems to make their own decisions, run their own lives and provide support for one another (1990, 1978).  While the normative claims of recovery have been adopted within English policy, its implementation in mainstream services is heavily critiqued by service users; the main point being that recovery has come to mean all things to all people (MIND, 2008).  Indeed there is a risk that its increasingly popular status and dominance as a paradigm within policy discourses will lead to it being co-opted and distorted by policy makers and experts in the field.

With colleagues in the School of Nursing we used Noam Chomsky’s critical methodology, as an exemplar of a left libertarian position, (Edgley, 2000; 2005; 2009) to provide a theoretical analysis and test of the coherence of the recovery model (Edgley et al., 2012).  We also used it as a critical mechanism to judge manifestations of recovery in practice settings.  In Chomsky’s political philosophy we find that hope is both a pre-requisite and a pre-condition for a trusting and supportive environment.  Everyone, whether or not they have mental health problems, need these conditions to be able to access and utilise their creativity in dealing with their current reality.  For Chomsky, hope, our innate creativity and a supportive community are the necessary conditions of freedom.  In Chomsky’s view, if our society nurtured our creative potentials, then our human nature would not confine itself to searching for autonomy and independence but would instead generate interdependent arrangements.  This could have direct implications for the implementation of recovery; it suggests that those experiencing mental ill health need to be the co-creators of policy and practice, rather than its passive recipients and they need to be able to build and use their own theoretical structure such as that offered by Chomsky.  This would protect recovery from being ideologically driven and open to political interpretation and potentially more importantly provide the basis to evaluate and present evidence on its own terms.  As we conclude in the article:

“The recovery paradigm has the essential elements in place, but control over its application – and lives- needs to be reclaimed from the state and experts alike before adoption turns to assimilation or perhaps co-option turns to emasculation.”

Posted by: Dr Nicola Wright Research Fellow: Research Delivery and Support Unit Collaboration for Leadership in Applied Health Research and Care (CLAHRC) Nottinghamshire, Derbyshire and Lincolnshire

References Edgley, A (2000) The Social and Political Thought of Noam Chomsky.  London: Routledge.

Edgley A (2005) Chomsky’s political critique: Essentialism and political theory.  Contemporary Political Theory 4: 129-153.

Edgley A (2009) Manufacturing consistency: Social science, rhetoric and Chomsky’s critique special issue: The Herman-Chomsky propaganda model twenty years on.  Westminster Papers in Communication and Culture 6(2): 23-42.

Edgley A, Stickley T, Wright N and Repper J (2012) The politics of recovery in mental health: A left libertarian policy analysis.  Social Theory and Health 10(2): 121-140.

MIND (2008) Life and Times of a Supermodel.  The Recovery Paradigm for Mental Health.  MindThink Report 3.  London: MIND.

Scull A (1981) Madhouses, Mad-Doctors and Mad-Men: The Social History of Psychiatry in the Victorian Era.  Philadelphia: University of Pennsylvania Press.

 

A short way down from the Department of Health building on Whitehall stands the statue of Field Marshall William ‘Bill’ Slim. Much beloved by his troops from the Burmese conflict in World War Two, there are stories that Slim was unusual in getting things done. One tale about setting up a new camp was that he would insist that sappers delayed laying paths and roads until it had become clear which directions had attracted the most use, usually the paths of most convenience or efficiency.

In a way this tale expounds both a ‘custom and practice’ approach as well as exhibiting innovation. After all how often have we seen organisations or systems insisting on doing things in a way that seems long-winded or inefficient? Human nature sometimes overtakes procedure and staff adapt an approach to save time or effort. Of course, one person’s short-cut is another’s health and safety nightmare. Knowing when it is safe to take a short-cut to improve a pathway is the key.

On my way to my office I get the chance to alight from the tarmac path onto the spongy turf. It isn’t far from the path but that briefest of periods puts the spring back in my step, changing my mindset and for a split second I feel and think differently about things. In his new book ‘Imagine: How Creativity Works’[1] Jonah Lehrer notes how new ideas and solutions to problems often arise from such a change of context, particularly when we are relaxed or off-guard.

So, what am I saying? That we should all stroll randomly about the lawns of our organisations? The gardeners would hate it; our shoes would get muddy too. But there is something about pathways that is fundamental to integrated healthcare in the twenty first century, both in terms of utilising existing flows between hospitals and community care but also allowing ourselves to think differently about going metaphorically off-piste. Now is the time to use a Slim (or should that be ‘lean’ – to adopt the management term) approach to examine what works well and strengthen those pathways as well as looking for other paths across networks that cut off the corners. The trick of course, as with all new ideas, is to get the right meld of innovation, pragmatism and efficiency. Easy to say….

Posted by:
Dr John Milton
Consultant Forensic Psychiatrist & Forensic Research Lead
Rampton Hospital Nottinghamshire Healthcare NHS Trust
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Reference:
[1] http://www.jonahlehrer.com/