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Throughout October, we're showcasing our Nottinghamshire Healthcare colleagues, and the path they have taken into research. To discover Your Path in Research, visit the National Institute of Health Research website for information and inspiration.

Throughout October, we're showcasing our Nottinghamshire Healthcare colleagues, and the path they have taken into research. To discover Your Path in Research, visit the National Institute of Health Research website for information and inspiration.

Throughout October, we're showcasing our Nottinghamshire Healthcare colleagues, and the path they have taken into research. To discover Your Path in Research, visit the National Institute of Health Research website for information and inspiration.

Throughout October, we're showcasing our Nottinghamshire Healthcare colleagues, and the path they have taken into research. To discover Your Path in Research, visit the National Institute of Health Research website for information and inspiration.

Throughout October, we're showcasing our Nottinghamshire Healthcare colleagues, and the path they have taken into research. To discover Your Path in Research, visit the National Institute of Health Research website for information and inspiration.

Someone close to me asked me which psychiatric tablet that I take helps me the best. I thought for a few seconds and then replied that actually it wasn’t a pill that helped me the best, but a ‘thing’ - validation. They replied quite honestly that they didn’t know what validation was. So I told them...........

I have blogged before about my journey of mental health distress, about how I found peer support and became an accredited peer support worker. I have blogged about relapse and how that has shaped my journey - I have talked about some of the challenges I have encountered on my recovery road, but now it’s time to talk about things that really matter to me. The things that are forming the concrete foundations that I am building, tools that I can use in my own recovery but also tools I can use to help those I have the privilege of working with.

So, to validation, I could easily give you many a dictionary definition to peruse but in short, validation is making someone’s experience ‘valid’, ‘real’ and ‘true’. If you can do this for someone then you have the power to help them in greater ways than any medication, I believe. Let me give you some examples. I have recently experienced a rapid relapse, that was scary, full of visual and auditory disturbances and scary shadows that were everywhere. For those of you that have experienced such things you will know that telling someone who works in mental health services what you can see and hear is very hard - you worry what they will say, you worry they will call a mental health act assessment - you worry that they will take away your choices - but above all, for me anyway, you worry they won’t believe you! To share something so scary, to ask for help is something I find really hard, and sadly in the past, people have said things like ‘pull yourself together’, or they try to minimise your experience by saying ‘oh it’s all in your mind’ or ‘other people have it worse’.

How wonderful and powerful it is then, to be with someone who will truly validate what is happening to you - they will say things like ‘that must feel so scary Clare’ or ‘I can’t imagine what that must feel like Clare’. Or even ‘I believe you, and I believe in you’. Thus acknowledging that they can’t take those experiences away but they can sit with you in your distress and help you find fresh avenues to reduce the intensity of your emotions. Validation, when truly experienced can help to safely minimise your distress and for me it creates strong bonds of trust that allow you to walk bravely in the darkness of your experience. How powerful is that?!

I love this quote by Danielle Bernock which says:

 “Trauma is not personal, it does not disappear if it is not validated. When it is ignored or invalidated the silent screams continue internally, heard only by the one held captive. When someone enters the pain and hears the screams, healing can begin.” Validation is so important, so crucial to healing and recovery, yet many people jump to fix or dismiss the suffering being felt. This can be equally frustrating for both parties.

When I think of my own relapses, I can recall occasions where I felt unheard, yet was desperately screaming inside for help. I can also think of times more recently where someone has said ‘I hear you’ and the difference it makes is truly amazing.

Being a peer support worker, the reciprocity of sharing feelings and experiences is so powerful and I feel honoured to sit with someone in their distress - but as a person who has experienced trauma, I KNOW the wonderful feeling when I have really been heard.

Validation, it’s priceless.

……………………………………………………………………………………………………………………

Clare Knighton is an accredited peer support worker based in Worcestershire.

@knightonstar

   

Whilst attending the World Psychiatric Association International Congress 2012 Conference (held 17-21 October), Rex Haigh, an NHS consultant psychiatrist, wrote a blog post for every day of the conference.   With a packed conference schedule of activities from 6:30am to 11pm, Rex reported on the variety of presentations, themes and discussions that emerged over the five days.   To highlight the conference, we have selected one post to reblog in full, covering the presentation from Rex's team and a variety of poster and speaker presentations from Day 2: More than 17 (just).

We would highly recommend checking out the rest of his posts as it appears to be an excellent conference with thought provoking themes arising.  To access all of the conference daily posts, please see the following on Rex’s blog:

The Yerkes-Dodson Test (Day 1)
(Day 2 is posted below)

Ulysses or Lithium? (Day 3)
Wheeling, Dealing and Scheming (Day 4)
The Kindergarten of Democracy (Day 5)
 
Featured Post by Dr Rex Haigh: More than 17 (just) 
Arriving for breakfast at 0632, I was surprised (and very pleased) to see I was
the last one there. We ate rather silently and nervously, and got the metro to
arrive in our presentation room just after 7am. We put up our display posters
either side of the stage, and leaflets on all the seats; we adjusted Yousuf’s
powerpoints a few more times,and finally handed it over to the technicians.
Then we waited…


Although there were only 3 attendees there on the dot of 0800 (our official starting time), somebody did say that lots more were outside the congress centre, just arriving – so we waited a few minutes before starting.

Soon there were 17 and by the end we had about 30, though there was some coming and going. The talks went pretty well exactly to time and to plan, and are available on the LLE website www.livinglearningexperience.com.  Afterwards, we breathed a sigh of relief and had the freedom to enjoy the rest of the congress.

[caption id="attachment_581" align="alignnone" width="300"] Nearly 17 by now


C B Nemeroff (USA) gave the first plenary lecture – on Neurobiology of Child Abuse and Neglect – and gave a dazzling exposition of the genetic, neuroimaging and pharmacological bases of adult consequences of childhood trauma and abuse, and how the people with histories of maltreatment had different brains. Although he seemed to deliberately avoid the PD label, it was almost a return to the days of ‘endogenous v reactive’ depression – except over a life course, rather than weeks or months. Quite reassuring to those of us who fear being eclipsed by the biomedical juggernaut driven by the economics of the pharmaceutical industry.

Then to the posters – hundred of them from all over the world; interestingly all of those from latin countries bearing a prominent ‘no conflict of interest’ declaration, none of which would have suggested any such suspicions. Is this an international version of the UK ‘health and safety’ culture, used to destroy trust and spread persecutory anxiety? And next to the poster, a display of restraint cages through the years, and straitjackets exhibited like a fashion display. Was this deliberate irony?

[caption id="attachment_582" align="alignnone" width="300"] Bed shortage?


[caption id="attachment_583" align="alignnone" width="300"] C&R?


[caption id="attachment_584" align="alignnone" width="300"] PICU?


[caption id="attachment_585" align="alignnone" width="300"] Straitjacket couture?


Next to a heart-warmingly reassuring session by Czech psychiatrists and therapists from The International Centre for Integrated Psychotherapy (Knobloch). Heart-warming because it was human-scale and clinical, reassuring because it is a TC by any other name. Although they only briefly referred to TCs, I asked if they recognised the British TC tradition, with Maxwell Jones and all, as their work seemed so familiar: and indeed they did. Somehow, we should be making friends with groups like this.

Towards the end of the afternoon, were workshops. The title of ‘Innovation in Psychotherapy Education’ was catchy enough to attract me, but for some reason, my heckles were soon raised once there. It was a sharply commercial presentation of an elegant and well constructed Moodle website for training in basic psychotherapy – not unlike KUF in its design, but lacking the radical ‘relational’ edge that I think is essential in any therapeutic engagement. A sales pitch, I suppose, when I was looking for realttitude change, I suppose – tackling ‘us & them-ness’ – ever seeking that dear old ‘quality of relationship’ again.  After an initial altercation which Yousuf and I had with the presenter – about the viability of hard evidence-based rules for all psychotherapies – I meekly shut up and watched nigh on a dozen video clips of very self-assured therapists teaching how to do CBT…

The final session was much more cheering, though. Professor R S Murthy was being presented with a special prize. The purpose, structure and committee for this prize was explained at great length before the ceremonial exchange of gifts and flowers and the lecture could begin. Professor Murthy is recently retired Dean of the NIMHANS – ‘the Maudsley of the Subcontinent’ in Bangalore – and I explained to him before the talk about our link with ASV and the intention to do an LLE there in the next year or two. Maybe we should do a second one for NIMANHS residents! But he was great – talking our language like few others did here.
Here’s the points from two of my favourite slides of his. This one gave seven criticisms of the current ways of psychiatric thinking and practice:

1.       Medicalisation of suffering
2.       Vague diagnosis
3.       Mainly pharmacological interventions
4.       Doubtful outcomes
5.       Insensitivity to local customs and practices
6.       Loss of personal context
7.       Psychiatric imperialism

• Recognition of the central role of people and families
• Information and interventions for them
• Professional development to share this

[caption id="attachment_638" align="aligncenter" width="300"] Cumberland Lodge (Windsor Great Park)


The Consortium for Therapeutic Communities (TCTC) hosted its first annual conference last month, 22-24 October 2012.  Held at the beautiful and scenic Cumberland Lodge within Windsor Park, it was an opportunity for those interested and/or working in therapeutic communities (TCs) to come together.  The conference itself has been running for several years, organised by the 40-year old Association of Therapeutic Communities (ATC).  Significantly, this was the first year that the newly formed TCTC, which took over from the ATC earlier this year, hosted the event.   This year’s conference theme was ‘Delivering Integrity’.*

I am relatively new to the TC world and this was my first time attending the conference.   This was like no other conference I had attended.  It was not just that each day started and ended with a community meeting (60+ individuals sitting in a circle, talking and reflecting as a group on the days’ events), the Greek dancing, the multiple cheerful toasts at dinner, or that at times the conference resembled a type of family reunion; it was more the atmosphere and purpose of this conference that set it apart.

On the first day, members of the TCTC (formerly members of the ATC and Charter House Group) had the opportunity to vote for the first TCTC board of directors.  This was no small thing – it was not only saying goodbye to 40 years of the ATC, it was asking the question, what do we want next?  Conference delegates had the task of discussing the future direction of TCs, what type of organisations/communities TCs should include (or perhaps more importantly, exclude), what the ‘mission’ should be, building a solid research evidence base, lobbying and advocating for community approaches within mental health / education / social care, and how the TCTC should go about all of this.  There was much discussion and debate; however despite the variety of voices in the room, it was clear that the current direction of TCs has to change to become more proactive, rather than reactive, to changes in government policy and funding.  For some, this sparked feelings of loss at having to let go of the old.  For others, especially those of us who are new to the TC world, it felt rather exciting and optimistic.

Having ushered in TCTC and started the conversation as to the future of TCs, Day 2 of the conference moved on to explore ‘Promoting Integrity’.   To that end, presentations included a keynote address from Professor Colwyn Trevarthen titled ‘The Social Brain: The Healing Power of Emotions’; a talk by Mark Johnson, ‘Reclaiming Integrity after a Destructive Childhood’; and Leonie Cowen, ‘Integrity in Commissioning: Ensuring Needs are Met’.

[caption id="attachment_639" align="alignleft" width="258"] Drawing Room - where 3 stories of personal change were given (Day 3)


Day 3 of the Conference, which specifically looked at ‘Demonstrating Integrity’, included a presentation from the TCTC Research and Development Group, research paper presentations, life stories of personal change, and a presentation and video on the MAL-HER-JUST-ED project (for more info about this project, please see the Performance and Workshops section on the Therapeutic Living with Other People’s Children website).

At the final community meeting of the conference, the feeling in the room still held one of excitement and of hope for the future of TCs.  Whether that can be translated and then sustained in terms of real life policy and funding challenges remains to be seen.  However I am an optimist, and as an American my faith in the optimist approach was restored in last week’s US presidential elections.

[caption id="attachment_641" align="alignright" width="289"] President Obama


Just like Obama managed to pull off a re-election win during trying times in American (and world) history, I would like to believe that TCs too will find a way through the funding cuts, the individualist and at times isolationist approach to mental health and social care.  But, as with Obama, there is real work to be done as the challenges and oppositions we face will be with us for some time.  And will likely get worse.  So the question remains, despite all of this, what will 40 more years of TCs bring?

(*NB: Rex Haigh also wrote a blog post about the TCTC Conference: TCTC: born 22/10/12, Windsor, England.  As a regular conference attendee for many years, he provides a much more in-depth perspective about all these changes and talks more fully about the presentations and speakers.  I highly recommend it!)

Posted by:
Jenelle Clarke
ESRC PhD Student (Sociology)
E: This email address is being protected from spambots. You need JavaScript enabled to view it.

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.

Ever had a re-occurring health problem making time off work an ever increasing problem? Add on top of that a mental health difficulty, and what do you get? In my case very anxious and an enormous feeling of guilt: ‘If I don’t go to work they will think I am pulling a fast one’.

My physical health has been poor these last four years with numerous leg operations. For those of you who have known me for a while you will have grown close to my moon boot, crutches, and plaster. I have seen research showing that those individuals with mental health problems and are employed have a better attendance than those without mental illness. Within my circle of friends I have seen that a lot and am very proud of those that keep themselves in work under self-pressure to keep going. Work is difficult for us all at times, we all have things happening outside of work which can impact on our attendance, but if you add mental health problems to the equation then stress can be exacerbated.

I would be interested in hearing from anyone who may have done research in this area or is contemplating doing so. I do know there is still a lot of stigma around employing people like me. I have the Personality Disorder label and do find some days hard but that shouldn’t stop me going to work. We all have bad days. I don’t give up easily and would advocate work as a real and useful distraction. I remember my first coping strategy when I realised I needed to evade violent and intrusive thoughts was to put the kettle on.  I do it as second nature now, as well as coming to work. I have a great bunch of friends and colleagues in the Institute of Mental Health and look forward to coming to work each day. Instead of sitting on the sofa as I did for ten years doing nothing. Over the last few months I have felt like going back to that sofa but you know I would miss the life I have now with all my friends and colleagues and to be honest I can now go on holidays; for example, I love to go cruising.

Don’t forget, if you need a forum to take research ideas to, let me know at the MHRN and we will get some service users and carers together to help you.

I look forward to seeing you when I get back from my operation.

Posted by:
Debbie Butler
Patient and Public Involvement Officer
NIHR Mental Health Research Network
East Midlands Hub

Last week the Schizophrenia Commission, headed by the mental health charity Rethink, released its report into the current state of care in the UK for people diagnosed with Schizophrenia. It made predictably depressing reading. Amongst other things, employment rates for people diagnosed with schizophrenia are less than 7%. The life expectancy rates are 15-20 years lower than the general population due to physical health-related problems. These health problems are often associated with weight gain, side-effects from powerful anti-psychotic medications. A huge proportion - 87% - of service users report experiences of stigma and discrimination, whilst the cost of schizophrenia to the economy was estimated at around £11.8 billion.

Perhaps even more depressing was report’s findings into the current state of mental healthcare in the UK for people diagnosed with schizophrenia. Mainstream psychiatric care was described as “a broken and demoralised system that does not deliver the quality of treatment that is needed”, in which service users “feel shuttled from one team to another as if on a factory production line”. Inpatient wards are often “frightening places where the overwhelmed nurses are unable to provide basic care and support” and in some cases “so anti-therapeutic that when people relapse and are in need of a period of care and respite, they are unwilling to be admitted voluntarily”. Too often, “medication is prioritised at the expense of the psychological interventions and social rehabilitation” and genuine service innovations like Early Intervention is Psychosis (EIP) teams are “vulnerable to service cuts”. The net result of all this is that psychiatric care “adds greatly to their distress and worsens the outcomes for what can already be a devastating illness”.

As someone who has experienced psychosis, been sectioned, diagnosed with schizophrenia, spent time in an alternative therapeutic community, qualified as a clinical psychologist and worked for two years in an EIP service in London, I can relate to much of this. I found my inpatient stays traumatic and demoralizing. As a result of medication I put on four stone of weight in 6 months. I used cannabis to cope, which of course led to more long-term problems. Thankfully I was helped by an alternative therapeutic community; the love and kindness showed by people in the community helped repair some of the damage from my experience as a psychiatric service user. Supportive but challenging relationships were key, as in fact they always are (Pilgrim et al., 2009).

So before we become self-satisfied with smug complacency about having better attitudes towards severe mental illness than wider society, perhaps we should get our own, crisis, house in order. Attitudes amongst mental health staff can still reflect negative, and inaccurate, expectations of people diagnosed with schizophrenia; in one study for example (Nordt et al., 2006), psychiatrists’ attitudes were more negative than the general population. Health professionals with past or present experience of mental health difficulties are often less likely to disclose their problems to colleagues than people outside the health service (Hinshaw, 2008).

When I was working at a large, well-known mental health research institution a senior colleague once told me, “you only got the job because of your psychiatric history, not because you are a good researcher”. When, whilst working at another NHS Trust, a confused visitor looking for an A & E department was told by a receptionist, “No, no love you’ve got it wrong; this is not a real hospital, this is a hospital for mental people”. The receptionist helpfully added a circular motion beside his head to illustrate what he meant by ‘mental’, just in case the flummoxed visitor (and, presumably, the patients and carers waiting in reception) didn’t understand.

Those in glass houses…

Posted by: Dr Simon Clarke Clinical Research Psychologist Nottinghamshire Healthcare NHS Trust

References: The Schizophrenia Commission Report (2012): http://www.schizophreniacommission.org.uk/the-report/.

Hinshaw, S.P. (2008) Breaking the Silence: Mental Health Professionals Disclose Their Personal and Family Experiences of Mental Illness. New York: Oxford University Press.

Nordt, C., Rossler, W. & Lauber, C. (2006) Attitudes of Mental Health Professionals Toward People With Schizophrenia and Major Depression. Schizophrenia Bulletin 32(4): 709–714.

Pilgrim, D., Rogers, A. and Bentall, R. (2009) The Centrality of Personal Relationships in the Creation and Amelioration Mental Health Problems: the current interdisciplinary case. Health: an interdisciplinary journal for the social study of health, illness and medicine 13(2): pp.235-254.

Understanding teen stress, anxiety, and depression has been a major focus at the Institute of Mental Health blog this year. Today’s article, by American higher education expert Bree Hernandez, takes a closer look at how university students -- particularly those studying at the graduate level -- are impacted. Bree has made a career out of discussing the benefits of graduate education, and she is quite knowledgeable about student issues both in and outside of the classroom.

Mental Health Problems Continue to Plague Higher Education
Psychologists have increasingly noted that mental health issues among college students have been on the rise for more than a decade. While the entire college-level population is generally perceived to be at higher risk for depression, anxiety and other conditions than other adolescent or adult communities, recent data shows that occurrences are especially high among graduate students.

In 2010, the American Psychological Association (APA) reported that mental illness among college students had risen dramatically within the previous 10 years. Based on a survey of more than 3,200 American university students, 96 percent of students who visited their campus clinic for psychological treatment were diagnosed with at least one mental disorder. While cases of average depression remained the same (“relatively mild”), rates of severe depression rose seven percentage points between 1998 and 2009. Furthermore, doctors noted a steady rise in the number of students using medication to combat their mental issues. In 1998, 11 percent of students took medication for depression, anxiety, mood disorders and ADHD, among other conditions; in 2009, that number reached 24 percent. There is reason to believe it is still on the rise.

Margarita Tartakovsky, Associate Editor of PsychCentral, recently noted that graduate students are at the greatest risk of suicide. Based on a study conducted at Berkeley University, nearly half of all graduate student respondents suffered from an emotional or stress-related disorder that affected them on a daily basis. The demanding nature of graduate-level coursework – which is typically taught within a less structured environment than undergraduate studies – plays a crucial role in the mental health of grad students, Tartakovsky found. When coupled with the stress of accruing massive student debt in order to receive a master’s degree, the deck often seems stacked against the student. While 52 percent of stressed out graduate students considered receiving help from mental health assistance services, only 27 percent actually followed through.

To mitigate the negative consequences of mental health issues, many of today’s campuses provide accommodations to affected students. According to a report by the University of Washington, these accommodations may be made in regard to classroom policy (preferential seating, early availability of textbooks and syllabi), course examinations (extended time, assistive computer software) or assignments (relaxed deadlines, substitution). However, some of these accommodations may actually be doing students a disservice by customizing the academic experience to fit their specific needs. According to a report by the Jed Foundation, institutes of higher education should not “fundamentally alter” courses in order to accommodate students with mental health issues, nor should the schools incur an “undue burden” (logistical or financial) to make accommodations.

There is also a question of fairness, argues a recent report from a professor at the College of New Rochelle. “Accommodations allow students equal opportunity to participate in all aspects of college life,” the report states, “but should not provide unfair advantage over other students or fundamentally alter the nature of courses.”

Many experts today are touting low-impact strategies that students can employ as an alternative to campus-wide accommodations for individuals with mental health issues. Studies have shown that many first-year students enter university studies with pre-existing mental health conditions which have not yet been addressed, and seeking professional help prior to arriving on campus could mitigate some of the problems related to these conditions. And because many of these mental disorders are stress-related, health experts urge students to regularly exercise, get eight hours of sleep every night and refrain from frequent drinking or recreational drug abuse. And according to Psychology Today contributor Julie Hersh, all students can play a role in fighting mental health issues on campus by forming committees and support groups for affected individuals.

Students who suffer from mental health issues should not exclusively rely on counselor treatment or campus-wide accommodations in order to succeed in college. By practicing low-impact strategies like those listed above, affected men and women stand the greatest chance of completing their courses and earning a degree in spite of a debilitating mental disorder.

Well what a week. There has been progress with the MHRN Industry Group of service users and carers. This group has met twice now and are preparing to meet again in a few weeks.  The MHRN are pushing for more recruitment to these types of studies and although it is very complicated, we were privileged to have a good few people attend our first couple of meetings and give positive comments on being involved. The next meeting is the subsequent step where we discuss as a group the way forward and look at where we can get involved in the different studies. Personally I find it quite a difficult subject to understand but I am sure I will get there. (Perseverance is the key.) How can we as a small cog in such a massive, global enterprise make our way into what seems a very closed shop when often, so I have been informed that the large organisations that develop these studies have never ever involved the public and users of the medication that they produce. More positive things have happened within the MHRN - we seem to be ironing out difficulties which moving into the new building have bought about.

Another positive for me this week has been on a personal basis really and a big boost to my self-esteem. I have been asked by various members of IMH staff about patient involvement and have been glad to help. Thank you to those who have asked and if I can be of any help to others please let me know. My experience within the Trust has been over a good few years and I have met a quite a lot of individuals from doing this. My mum always asks me if there is anyone I don’t know. It’s not unusual for me to go out without seeing anyone from work or the classical music scene.  Keep fingers crossed for me, I am seeing a new singing teacher today based at the Uni.

Patient and Public Involvement for the MHRN took a great boost on Friday 27^th July as I went to the Rosewood involvement centre up in Ollerton to talk to their Friday Group about the MHRN and can I say, I came home feeling like I was walking on air.  The Friday group is a well attended group of service users and carers who get together for support and encouragement to each other and to hear about different things going on in the Trust and outside. The Rosewood centre is the sister Involvement centre to the one at Duncan Macmillan house and is a very thriving place to go. They even have their own belly dancing troop. There was so much enthusiasm from the entire group to listen, ask questions and equally wanting to become involved it was just astounding. Can I post a great big thank you to them all. I have so many contacts to make and friendships to develop, it was extraordinary.  The MHRN as an organisation is obliged to involve service users and my job is to co-ordinate the involvement and recruitment to different research studies. The boost from attending the Rosewood centre was that we could form a group in the North Nottinghamshire area and help researchers who can sometimes be Nottingham centric develop studies in the north of the county. I am sure the group would be very useful. The wealth of experience is an added bonus to anyone in the field of research.

I was one of the first service users to be employed by the Trust way back in 1999 (I think it was then). And have seen a tremendous development in this area. I cannot thank all my friends and colleagues enough for their hard work in developing Involvement. It started off with one young man called Liam O’Neil who sadly is no longer with us but his name is kept alive with one of the Trusts OSCARS bearing his name, and has developed into quite a large staff team.  Liam was a service user who I met when I was a volunteer at the Nottingham Advocacy group; he was quite a cautious man but was very vocal and knowledgeable around involvement of service users in any aspect of their care and the organisation of the Trust. Liam worked on his own to begin with to set up the involvement department in the Trust until a manager was appointed then things seem to go all out to what we have today, two Involvement centres.

Posted by:
Debbie Butler
Patient and Public Involvement Coordinator
NHIR Mental Health Research Network
Mental Health Research Network
East Midlands Hub

The following post is written by Dr Rex Haigh, blogger for Struggling to Be Human: what we're up against, originally posted on 17 June 2012 entitled 'Has CBT killed the human spirit?'.
Much as psychoanalysis set the cultural tone for our understanding and conduct of relationships for most of the twentieth century, cognitive behavioural therapy (CBT) has been leading us into a much less forgiving place for the last twenty years or so.

[caption id="attachment_404" align="aligncenter" width="300"] CBT Circle


In the world of psychotherapy, CBT has numerous siblings and cousins: most with three letter abbreviations to make a multiflavoured soup of ‘alphabetti spaghetti therapies’. Two flavours of the month are Dialectical Behaviour Therapy (DBT)  and Menatlisation Based Therapy (MBT). DBT, with its trendy 'mindfulness' plus new age and hippy edge, give its authoritarianism a warm fuzzy feeling; mentalisation has considerable weight of respectability afforded to it by years of attachment research in the experimental psychology departments of prominent universities – and charismatic professors with superstar status to market it. There are many other manualised and packaged 'new therapies', easily findable with your favourite search engine. But my overwhelming feeling is that they are all missing the point, and engaged in a pointless horse race with celebrity status prizes for the academics who reduce the interventions to dumbed-down therapy cookbooks, and then make sure everybody is following the recipes with multivariate statistical analyses backed up by powerful regulators like NICE. To me, this all seems like a very elaborate, somewhat sinister and ruthlessly inexorable way of taking the essential human qualities of the therapeutic relationship out of the picture.

[caption id="attachment_405" align="aligncenter" width="300"] Mandala

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.

The NHS can’t afford to fund every new medical treatment. Budgets are limited. Resources are finite. It’s a boring fact of life, from which people like me – economists – benefit. In recent years the UK has championed the provision of cost-effective healthcare. The efficiency of the NHS owes no small thanks to NICE, which evaluates health technologies for all kinds of conditions. To do so they need to be able to compare these technologies with each other. The general consensus amongst health economists, and the approach adopted by NICE, is to use quality-adjusted life years (QALYs). QALYs are required by the NICE reference case and we have excellent tools such as the EQ-5D to capture these. The use of QALYs as an outcome is almost ubiquitous in the evaluation of health technologies. So much so that they have come to define cost-effectiveness. The area in which their use and study appears most limited is in mental health research. Herein lies a problem: from the decision-makers perspective, not knowing whether an intervention is cost-effective isn’t all that different from knowing that it isn’t.

Generic preference-based measures
Health technologies are competing for the same pot of NHS money and are therefore pitted against each other, regardless of dissimilarities in the conditions they treat. We therefore need an outcome measure that is relevant to all conditions; from baldness to bunions; abdominal pain to Zellweger syndrome. We need an outcome measure that is ‘generic’. For economists (and to some extent decision-makers), preferences are paramount. A hypothetical change in an individual’s health only matters if they (or, in practice, the public) actually assign any value to this health change. As such, the last few decades have witnessed the rise of generic preference-based measures. The EQ-5D is the most well-know of these, but others do exist. These measures enable researchers to calculate the benefits of an intervention in terms of quality and length of life – combined in to one number. Decision-makers are then presented with an illuminating ‘cost-per-QALY’ of an intervention. Such a minimalist result is of great value in funding decisions. Unfortunately, in many cases, economic evaluations in mental health are not armed with this figure. This is no doubt detrimental to future provision and research.

Condition-specific preference-based measures
Mental health researchers’ apparent unawareness of generic preference-based measures is justifiable. The EQ-5D, for example, only includes a single question relating to mental health. There are also greater methodological problems with using generic preference-based measures in mental health; are public values representative of patients’ preferences; can severe patients understand the questions; are ‘general’ questions even relevant? There are certainly pros and cons to using a measure like the EQ-5D in mental health research¹.

Fortunately there’s a happy medium that still allows for the calculation of QALYs and, therefore, the generic valuation of mental health technologies. Condition-specific preference-based measures. These measures capture changes in an individual's quality of life based on dimensions relevant to specific conditions. The development of a preference-based measure involves two stages: development of the classification system (questionnaire) and the elicitation of values. Unfortunately most existing measures have only completed the first stage. Nonetheless, measures do exist and I implore you to research them further, get involved in their development and include them in your studies. There are measures under development that are specific to particular mental health problems, such as DEMQOL: a quality of life measure for individuals with dementia². Some of the most promising work relates to the development of preference-based measures that are specific to mental health but general across disorders. This work includes development of a preference-based measure from the CORE-OM^3,4.

Where next?
Unfortunately these measures are almost solely employed and researched by economists. Researchers involved in the evaluation of interventions for mental health need to champion these measures, as economists alone cannot. If you’re a researcher, why not try to include fledgling preference-based measures (both general and condition-specific) in your studies, and aid their development. Cost-effectiveness is often an 'unknown' in mental health. This is no longer acceptable. If mental health research and care is to obtain the funding it needs, then researchers will have to bend to accommodate these methods and engage with economists. If you do nothing else please read this⁵, then read this⁶, and do not forget to read this⁷. The long-term benefits could be huge.

Posted by:

Chris Sampson
Health economist
University of Nottingham
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References
¹ Brazier, J., 2010. Is the EQ-5D fit for purpose in mental health? The British Journal of Psychiatry, 197(5), pp.348-9.

² Mulhern, B., Smith, S.C., Rowen, D., Brazier, J.E., Knapp, M., Lamping, D.L., Loftus, V., Young, T.A., Howard, R.J. and Banerjee, S. (2010) Improving the measurement of QALYs in dementia: Developing patient- and carer-reported health state classification systems using Rasch analysis. Discussion Paper. (Unpublished)

³ Mavranezouli, I., Brazier, J.E., Young, T.A. and Barkham, M. (2011) Using Rasch analysis to form plausible health states amenable to valuation: the development of CORE-6D from CORE-OM in order to elicit preferences for common mental health problems. Quality of Life Research, 20 (3). pp. 321-333. ISSN 1573-2649

⁴ Mavranezouli, I, Brazier, JE, Rowen, D and Barkham, M (2011) Estimating a preference-based index from the Clinical Outcomes in Routine Evaluation - Outcome Measure (CORE-OM): valuation of CORE-6D. Discussion Paper. (Unpublished)

⁵ Brazier, J., 2008. Measuring and valuing mental health for use in economic evaluation. Journal of health services research & policy, 13 Suppl 3, pp.70-5.

⁶ Jacobs, R., 2009. Investigating Patient Outcome Measures in Mental Health. CHE Research Paper 48, Centre For Health Economics: York

⁷ Chisholm, D., Healey, A. & Knapp, M., 1997. QALYs and mental health care. Social psychiatry and psychiatric epidemiology, 32(2), pp.68-75.

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/

The twenty-first century workplace can be a bewildering setting in which to spend most of your waking existence. Those of us in western professional jobs could be considered blessed compared with our ancestors. Few can complain about risks of physical injury or life-threatening injustice.

Scratch the surface, however, and there are frequent examples of mental health under strain: sleepless nights; anti-depressant prescriptions and loneliness, to name a few.

As an occupational psychologist, I have listened to many people’s experience of work. Quite a number have been in higher education across a range of institutions, others have been in a variety of professional jobs: social workers, architects and doctors amongst others. There are some almost universal themes.

Most people are coping. In fact, most are more than coping. They are often very successful. Their colleagues or clients would probably be amazed to hear that they feel fragile psychologically, some or all of the time.

Behind the scenes, however, many feel that there are few people they can trust. They feel in fierce competition with colleagues especially if there are redundancies in the air. Some feel a sharp sense of so-called imposter syndrome – living in fear that they will be exposed for not being as good at their job as others think they are. They may rarely experience a satisfying sense of a day well spent. They are trying to meet conflicting demands on their time. They are tired. They may have an increasing sense of being overlooked or side-lined for unclear reasons. They may feel that they “are owed” by their employer, after many hours of overtime, or having prioritised their work over their family or leisure time once too often. They may simply feel that they have an overwhelming workload.

This mindset arrives gradually. Most begin enthusiastically, and most continue to be enthusiastic about their field or subject, some (if not all) characteristics of their employing organisation, and at least some of their colleagues. But it can become a draining cycle of mistrust, exhaustion and conflict.

This often results in a modern fight or flight response. Going into meetings with all guns blazing, or maybe engaging in something of a more Machiavellian nature; or alternatively, working to rule in some way. This may mean working from home as much as possible; focusing on one or two aspects of the job that are considered to have most career benefit or are the most enjoyable; or withdrawing from contact with colleagues. These are all strategies. None of them is especially comfortable (or likely to meet organisational needs effectively) though.

It seems to me that this amounts to a threat to the professional population’s mental health which is often hidden from view. Collectively, how resilient are we? At a time when we arguably need to be ever more productive, creative and collaborative, how are we nurturing a mental strength and flexibility which is up to the task?

In the face of complex working challenges, both organisations and individuals often respond by working yet harder; demanding higher qualifications, longer hours, and, given the technological advances, to be available for work almost all of the time. True, a lot can be achieved by hard work.

But I like to imagine what we might achieve if the majority of us were feeling on top form, able to think clearly and work together to maximise our strengths and support each other. Maybe I’m idealistic.

Nevertheless, just imagine.

Posted by:
Sarah Dale

Sarah Dale is a chartered occupational psychologist and author of Keeping Your Spirits Up. She has a business background as a chartered accountant, and runs her own consultancy, Creating Focus. She is currently looking for inspiring women of age sixty plus to interview or to invite to write letters to her as part of her plans for her next book. For more details, contact Sarah on This email address is being protected from spambots. You need JavaScript enabled to view it. or 07748 494688.

Sarah’s website is www.creatingfocus.org and she can also be followed on twitter (@creatingfocus) or Facebook (Creating Focus).