Community Mental Health Practice Research Articles

Empowerment of Lay Mental Health Workers and Junior Psychologists Online in a Task-Shared, Rural Setting in Kerala, India.

Patients with severe mental health issues who live in isolated rural areas are difficult to reach and treat. Providing effective treatment is difficult because mental health problems are complex and require specialized knowledge from a range of professionals. Task-sharing with lay mental health workers (LMHWs) has potential but requires proper training and supervision to be effective. This article reports on the challenges and facilitators experienced in empowering LMHWs in their role, with the help of a technology supported supervision group. The study sought to understand the functioning of the Empowering Supervisory Group (ESG) in the context of junior psychologists and LMHWs in rural India, and investigate how they experienced it by exploring challenges, lessons and empowerment. Qualitative analysis of interviews with the 22 ESG participants and their supervisors. A total of three discrete phases of supervision were identified where supervisors responded to the changing needs of the group. This began with building trust at a baseline level, tackling issues with competence and autonomy and finally experiencing meaning and impact through self-determination. The experience of empowerment even in an online setting was very beneficial given the challenges of working in rural areas. Empowerment based supervision of LMHWs and junior psychologists online enables a level of engagement that positions them to engage in community mental health practices with greater independence and confidence.

Contributions of a time use perspective in community mental health practice: a scoping review.

Time use is an important indicator of health and well-being. Exploration of time use can provide in-depth information about individuals' activity patterns including routines and structure, the experience of activities, personal priorities and challenges. People experiencing severe mental illness may be at particular risk for time use patterns associated with poor health and wellbeing. This scoping review aimed to identify and map the evidence about how a time use perspective informs assessment and intervention in community mental health practice. Electronic databases and hand-searches were used to identify relevant studies involving people with severe mental illness, and focused on time use applications in practice. Twenty-nine studies were included in this review, data-extracted and synthesized with reference to the review question. Of the twenty-nine identified studies, seven described development and psychometric testing of time use assessments; twelve used time use tools to measure outcomes; and ten described or evaluated time use intervention approaches. The identified time use assessments typically involved retrospective diaries completed before or during structured interviews, and an Experience Sampling Method using smart technology to gather activity data in real time. Both psychosocial and occupational interventions used time use to measure outcomes relevant to activity engagement, social functioning, and personal recovery. The identified time use interventions originated in occupational therapy; included structured manuals and workbooks to enable reflection on daily time use; individual or group sessions to collaborate in identifying priorities, goal planning and supporting desired changes to activity patterns. These interventions were viewed favorably overall, with improved activity engagement, quality of life, and personal recovery reported. Time use assessments evaluate outcomes of importance to personal recovery and community inclusion. Time use interventions address activity patterns associated with poor health and wellbeing, using collaborative and supported activity engagement approaches, and contribute to emerging evidence on interventions that support personal recovery. Furthering peer involvement in developing and delivering these interventions will bring important insights to time use practice and research, while the social forces that marginalize or constrain activity participation for people with severe mental illness also need to be addressed to advance time use and other approaches that aim to support community inclusion.

How is physical healthcare experienced by staff, service users, and carers in adult community mental health services in a south London mental health trust? A service evaluation.

Adults with a serious mental illness (SMI) are at greater risk of physical health morbidity and premature death than the general population, largely as a result of preventable physical health issues. Staff working in mental health services have a role to play in addressing these inequalities, but little is known about how they perceive their role and how this impacts on their practice. Understanding this better would enable services to improve their approach and support better health outcomes for SMI patients. A service evaluation was undertaken to investigate how physical healthcare is approached within adult community mental health teams (CMHTs) at a South London (UK) Mental Health Trust. This was a prospective, cross-sectional evaluation design. Interviews and focus groups were conducted with clinical staff, service users and carers (non-professional caregivers e.g., family or friends, of adults living with an SMI), to understand their experiences and to identify key barriers and facilitators to supporting physical healthcare support for adults with SMI. Thematic analysis was conducted to identify key themes which were classified into five main categories. 50 participants took part in the study, 38 were clinical staff, eight were service users and four were carers. We found staff widely recognised the importance of supporting physical healthcare. However, there was variability in how staff approached physical healthcare in routine practice, and differences in how physical healthcare is experienced by service users and carers. Staff were keen to engage in changes to the way physical healthcare is delivered in CMHTs. However, they sought clearer guidance on their roles and responsibilities, and wanted to better understand the rationale for changes in community mental health practice, such as increased screening for physical healthcare. Service users and carers felt equally that the role of CMHTs in physical healthcare was unclear, which limited their ability to access it and understand the benefit for their overall care. Staff articulated gaps in leadership and training that impacted on their ability to implement the overall vision for physical healthcare within the Trust. Mental health staff recognise the role they play in supporting the physical health of adults living with SMI. This evaluation provides insight into common barriers and facilitators faced by staff, service users and carers when providing or accessing physical healthcare within adult CMHTs. These findings indicate a more comprehensive and better articulated approach to physical healthcare in mental health Trusts is needed to ensure service users and their carers understand what support is available and how to access it and to equip staff to provide and sustain that care in routine practice.

Power Redistribution and Upending White Supremacy in Implementation Research and Practice in Community Mental Health.

This Open Forum explores how implementation research and practice may sustain White supremacist ideas, perpetuate unequal power dynamics, and maintain mental health care inequities. The following questions were considered: What information is valued and considered evidence? and How do power differentials within implementation research and practice manifest? The implementation of evidence-based interventions within community mental health clinics is used as an example to explore these questions. Recommendations are provided to envision a future that centers collaboratively developed and community-led approaches to foster equity in mental health care.

Community mental health, psychoanalysis, and freedom: The case of Palestine

AbstractThe authors describe community mental health in Palestine from several vantage points: Palestine's historical and current context of military/political violence under Israeli occupation, its health care system and system of mental health care, and the status of its mental health staffing and training. Vignettes illustrate characteristic challenges and opportunities for Palestine within the domain of mental health. The roles of cognitive behavioral therapy and psychoanalytic thinking are discussed in terms of current practice, with an eye toward policy planning for a fully integrated model of health care delivery. The authors argue that the values of justice, freedom, and human rights are fundamental to well‐being, and that the theory and practice of community mental health must support active resistance to violation of these principles.

Therapist perceptions of experiential training for exposure therapy.

Despite evidence for its efficacy, exposure therapy for anxiety is rarely used in routine care settings. Efforts to address one major barrier to its use - therapists' negative beliefs about exposure - have included therapist-level implementation strategies, such as training and consultation. Experiential training, in which therapists themselves undergo exposures, has recently demonstrated feasibility, acceptability and preliminary effectiveness for increasing exposure use. This study aimed to assess: (1) therapists' perceptions of experiential training and (2) barriers and facilitators to implementing exposure following training. Therapists who underwent experiential training (n=12) completed qualitative interviews and quantitative questionnaires. Interviews were coded using an integrated approach, combining both inductive and deductive approaches. Mixed methods analyses examined how themes varied by practice setting (community mental health versus private practice) and exposure use. Results highlight how therapist-level factors, such as clinician self-efficacy, interact with inner- and outer-setting factors. Participants reported positive perceptions of exposure after training; they noted that directly addressing myths about exposure and experiencing exposures themselves improved their attitudes toward exposure. Consistent with prior literature, issues such as insufficient supervisory support, organizational constraints, and client characteristics made it challenging to implement exposures. Results highlight the benefits of experiential training, while also highlighting the need to consider contextual determinants. Differences in responses across practice settings highlight areas for intervention and the importance of tailoring implementation strategies. Barriers that were specific to therapists who did not use exposure (e.g. hesitancy about its appropriateness for most clients) point to directions for future implementation efforts.

The Meaning and Clinical Implications of Low MMPI-3 Self-Importance Scores

The Minnesota Multiphasic Personality Inventory-3 (MMPI-3) includes two self-concept-oriented scales: Self-Doubt (SFD), a measure of low self-esteem, and Self-Importance (SFI), a measure of beliefs that one has special attributes and abilities. Past research has demonstrated that SFD and SFI measure related but distinct constructs. The present study focused on explicating the meaning and clinical implications of low SFI scores. Using three clinical samples (private practice and community mental health and private practice neuropsychology clinics), we investigated whether the presence of interpretable low SFI scores (< 39 T) in the context of interpretable SFD elevations (≥ 65 T) is associated with distinctive MMPI-3 findings, and whether low SFI scores add clinically meaningful information in predicting relevant extra-test criteria. Consistent meaningful findings were obtained with respect to implications of low SFI scores for assessment of depression- and social engagement-related constructs. Additionally, the full range of SFI scores was meaningfully and negatively correlated with depressive disorder diagnoses and suicidal ideation but yielded very small correlations with suicide attempt and nonmeaningful correlations with diagnoses of Social Anxiety or Avoidant Personality Disorder. Hierarchical logistic regression analyses showed that SFI scores could meaningfully increment other related MMPI-3 scales in predicting diagnosed depressive disorders, albeit with small effect sizes.

From evidence to realities: psychosocial intervention provision in Australian routine community mental health practice

ABSTRACT Background This study explored care co-ordinator reports about provision of six evidence-based psychosocial interventions (PSIs) for people living with psychosis, to better understand decision-making about provision. Methods Conducted as an adjunct to the Second Australian National Survey of Psychosis in one catchment area, care co-ordinators completed a structured interview about evidence-based PSIs provided to 33 consumers as part of their community mental health care. Descriptive analyses were conducted. Results Care co-ordinators reported most consumers were provided at least one of the PSIs during the previous year; all were provided at least one non-evidence-based, typically briefer or simpler, alternative. Relapse Prevention Planning using early warning signs was reported as most provided; Family Psychoeducation was the least provided but rated as most helpful. The primary reason for non-provision of PSIs was that they had not been offered, with lack of relevance the most cited explanation. Conclusions PSIs may be more commonly provided than previously reported, if non-evidence-based alternatives are also considered: reasons for not offering evidence-based PSIs require further study. Meaningful guidelines are needed about when and how to offer PSIs in collaborative practice, including briefer or simpler interventions when preferred over more complex interventions.

APA Fall Conference to Focus on Determinants of Mental Health

APA Fall Conference to Focus on Determinants of Mental Health

Impact of Jointly Using an e-Mental Health Resource (Self-Management And Recovery Technology) on Interactions Between Service Users Experiencing Severe Mental Illness and Community Mental Health Workers: Grounded Theory Study.

Backgrounde–Mental health resources are increasingly available for people who experience severe mental illness, including those who are users of community mental health services. However, the potential for service users (SUs) living with severe mental illness to use e–mental health resources together with their community mental health workers (MHWs) has received little attention.ObjectiveThis study aims to identify how jointly using an interactive website called Self-Management And Recovery Technology (SMART) in a community mental health context influenced therapeutic processes and interactions between SUs and MHWs from their perspective.MethodsWe conducted a qualitative study using a constructivist grounded theory methodology. Data were collected through individual semistructured interviews with 37 SUs and 15 MHWs who used the SMART website together for 2 to 6 months. Data analysis involved iterative phases of coding, constant comparison, memo writing, theoretical sampling, and consultation with stakeholders to support the study’s credibility.ResultsA substantive grounded theory, discovering ways to keep life on track, was developed, which portrays a shared discovery process arising from the SU-worker-SMART website interactions. The discovery process included choosing to use the website, revealing SUs’ experiences, exploring these experiences, and gaining new perspectives on how SUs did and could keep their lives on track. SUs and MHWs perceived that their three-way interactions were enjoyable, beneficial, and recovery focused when using the website together. They experienced the shared discovery process as relationship building—their interactions when using the website together were more engaging and equal.ConclusionsJointly using an e–mental health resource elicited recovery-oriented interactions and processes between SUs and MHWs that strengthened their therapeutic relationship in real-world community mental health services. Further work to develop and integrate this novel use of e–mental health in community mental health practice is warranted.

Community Mental Health Practice in the United States: Past, Present and Future.

Similar to trends in Europe, approaches to mental illness in colonial America and recorded in early United States history were commonly characterized by incarceration and the removal of individuals from communities. In the mid-20th century, a major shift began in which treatment was offered in the community with the aim of encouraging individuals to rejoin their communities. In this paper, we will provide a brief history of community mental health services in the United States, and the forces which have influenced its development. We will explore the early antecedents of community-based approaches to care, and then detail certain factors that led to legislative, peer and clinical efforts to create Community Mental Health Centers. We will then provide an overview of current community mental health practices and evolving challenges through to the present day, including the development of services which remain focused on recovery as the ultimate goal.

Nonprofit leaders urge state to work with advocacy groups in solving mental health access

Several leaders of disability advocacy groups recently sent a letter to a Mississippi state agency requesting that the newly appointed coordinator of mental health accessibility include them in conversations on how to improve access to mental health services in Mississippi, the Daily Journal reported Nov. 18. On Oct. 28, the executive directors of the Coalition for Citizens with Disabilities, Disability Rights Mississippi, Families as Allies and Life of Mississippi wrote a joint letter to Liz Welch, director of the Mississippi Department of Finance and Administration, outlining different ways advocacy groups could be beneficial to improving mental health in the state. “Each and every day, we work with people whose lives bear witness to the fact that Mississippi does indeed discriminate against people with mental illness and, as a result, unlawfully segregates them in institutional settings, in violation of the Americans with Disabilities Act,” the letter reads. The group wrote that they have extensive knowledge about community mental health practices in other states, models of mental health authorities, and relevant documents and information to help assist the state in making im‐provements. Last month, Welch appointed attorney William Rosamond to the Mississippi Department of Mental Health as the coordinator of mental health accessibility. Joy Hogge, the director of Families as Allies, told the Daily Journal that even though there are some reservations about Rosamond's ability to be objective and impartial in his analyses, she hopes he can help facilitate a remedy to the state's broken mental health system and work with advocacy groups.

Managers’ perceptions of competence and practice development following education in the prevention and management of staff-directed aggression: promoting person-centred practice

Background: Staff-directed aggression and violence may have harmful implications for all parts of a mental health service organisation. In an effort to advance the development of competent practice in community mental health and substance abuse services in Oslo, the municipality has offered various courses in the prevention and management of staff-directed aggression and provided supportive tools for practice development. Aim: To explore managers’ perceptions of how participating in education and applying supportive tools have contributed to the development of competence and practice in their own services. Method: Qualitative interviews with 11 managers working in homebased community mental health services were analysed, using qualitative content analysis. Findings: The findings show education and application of tools contributed to: 1) increased awareness and understanding of the complexities of staff-directed aggression; 2) empowered and collaborative practice through negotiations of power relations; and 3) adjustment of perceived management responsibilities and assignments. Conclusion: The findings indicate that managers not only felt their staff had become more knowledgeable and competent following education, but that participation in education also impacted on collaboration within and outside their own services, as well as directly influencing how they dealt with threatening situations in the workplace. Implications for practice: Staff-directed aggression is a complex phenomenon and efficient practitioners are able to keep in mind a number of relevant aspects of practice simultaneously Collaboration in prevention and management of staff-directed aggression requires staff to acknowledge and accommodate service users’ perspectives regarding practice A levelling of power differentials between community mental health services and specialist mental health services takes place when partaking in the same education and sharing vocabulary and conceptual frameworks regarding risk assessment and management

A heuristic model for collaborative practice \u2013 Part 1: a meta-synthesis of empirical findings on collaborative strategies in community mental health and substance abuse practice

BackgroundCollaboration has become a cornerstone for healthcare practice in recent decades resulting in the efforts at international and national levels to integrate the concept into healthcare practice and services. However, there is a paucity of research delineating strategies for professionals to apply in collaborative practice with clients in general as well as in mental health and substance abuse (MHSA) care.MethodsThe method applied in this paper is a form of qualitative meta-synthesis referring to the integration of findings from multiple qualitative studies within a program of research by the same investigators. Eighteen empirical papers with the focus on community MHSA practice and recovery-orientation with relevance to the service user–professional relationship in MHSA practice were included in this meta-synthesis.ResultsThree types of processes of collaboration specified by meta-themes were identified. The meta-themes of the interactive-dialogical process type include (a) maintaining human relationship, (b) walking alongside, (c) information sharing, (d) seizing the present moment, (e) taking the perspective of the other, and (f) aligning/scaffolding. The meta-themes of the negotiated-participatory engagement type include (a) feedback-informing process, (b) putting differences to work, (c) negotiated partnering, (d) accommodating user participation, and (e) addressing the tension between help and control. The meta-themes of the negotiated supportive process type are (a) helping in context, (b) coordinating, (c) pulling together, (d) advocating, and (e) availing. These meta-themes are strategies for collaboration applicable in MHSA practice.ConclusionsThis meta-synthesis of collaborative processes found in community mental health practice points to the possibility of developing a set of repertoires of practice for service user/professional collaboration, especially in community MHSA practice.

Meeting the Developmental Needs of Young Adults Diagnosed with Serious Mental Health Challenges: the Emerge Model.

Adult providers struggle to engage 18-25-year olds despite high rates of serious mental health challenges observed among this age group. A new model, called "Emerge," combines the intensive outreach and multidisciplinary team-based approach used in Assertive Community Treatment with Positive Youth Development principles and practices used in the Transition to Independence Process Model. Emerge bridges youth and adult services, focuses on supporting transition-to-adulthood milestone achievement, and is a sister team to Coordinated Specialty Care for recent psychosis onset. This paper describes Emerge components, practices, and findings from a feasibility pilot study using agency administrative data. Most prevalent goals were employment and social support/relationship related. The majority made progress on individual goals, engaged in employment and education, and experienced decreased psychiatric hospitalizations. Community mental health policy and practice implications are discussed, including funding blending of evidence-based practices for those transitioning to adulthood with youth-onset serious mental health conditions.

Characterizing the heterogeneity of clinician practice use in community mental health using latent profile analysis

BackgroundThe behavioral health service provider population is highly heterogeneous. However, it is rarely treated as such within evidence-based practice implementation efforts. This study aimed to evaluate, as a proof of concept, the utility of latent profile analysis to identify distinct profiles of clinician practices in a large sample of youth-serving community mental health clinicians. This study also aimed to identify predictors of profile membership to inform implementation efforts.MethodsParticipants were 484 practicing clinicians (79.4% female, 45.7% White, M age = 37.1 years). As part of a larger survey, clinicians reported on their use of cognitive, behavioral, family, and psychodynamic treatment techniques with a representative client on their caseload. Latent profile analysis was used to determine the presence of clinician practice profiles. Multilevel multinomial logistic regressions examined predictors of profile membership.ResultsLatent profile analysis indicated a 4-profile solution best fit the data, with clinicians who: 1) used generally low levels of all examined techniques and preferred cognitive techniques (Low Eclectics, 16%), 2) delivered moderate levels of all techniques (Moderate Eclectics, 53%), 3) demonstrated preference for use of family techniques (Family Preferred, 11%), and 4) used high levels of all techniques (Super Users, 20%). Clinician discipline (e.g., social work), education, and years of experience predicted profile membership.ConclusionsFindings from this proof of concept study underscore the utility of latent profile analysis to characterize the complex and heterogeneous makeup of community mental health. Results extend prior work highlighting the eclectic nature of community mental health practice. Predictor analyses underscore the important influence of clinician background characteristics on practice use.

Exploring the Role of Social Support in Promoting Community Integration: An Integrated Literature Review.

Community integration has emerged as a priority area among mental health advocates, policy makers, and researchers (Townley, Miller, & Kloos, 2013; Ware, Hopper, Tugenberg, Dickey, & Fisher, 2007). Past research suggests that social support influences community integration for individuals with serious mental illnesses (Davidson, Haglund, Stayner, Rakfeldt, Chinman, & Tebes, 2001;Davidson,Stayner,Nickou,Styron,Rowe,&Chinman,2001; Wong & Solomon, 2002), but there has not yet been a systematic review on this topic. Therefore, the purpose of this paper was to explore the influence of social support on community integration through a review of the existing literature. An extensive literature search was conducted, resulting in 32 articles that met the search criteria. These articles were organized into three categories: defining community integration, supportive relationships, and mental health services. The search results are analyzed according to the types of support being provided. Article strengths, limitations, implications, and future directions are also addressed. Overall, the findings of this review suggest that social support, which may be provided by a variety of individuals and services, plays an important role in promoting community integration for individuals with serious mental illnesses. Therefore, as community mental health research and practice continues to promote community integration for individuals with serious mental illnesses, the mental health field should emphasize the importance of social support as a key factor influencing community integration.

‘The business end’: Neoliberal policy reforms and biomedical residualism in frontline community mental health practice in England

Mental health policy initiatives in England over the last three decades have led to significant restructuring of statutory service provision. One feature of this has been the reconfiguration of NHS mental health services to align with the requirements of internal and external markets. Based on findings from 12 months’ ethnographic fieldwork within one mainstay of NHS statutory provision, the community mental health team, this paper examines the effects of these neoliberal policy and service reforms on professional practice and conceptualizations of mental distress. The paper begins with an account of the restructuring of the labour process in community mental health services. This utilizes the notion of ‘strenuous welfarism’ to describe an organizational context characterized by escalating performance management, deskilling of professional practice and the intensification of mental health work. Increasingly prominent aspects of managerialism and marketization disrupted attempts by mental health practitioners to sustain supportive and mutual structures with colleagues and engage service users in therapeutic and relationship-based forms of practice. Moreover, organizational processes increasingly recast service users as individual consumers ‘responsibilized’ to manage their own risk or subject to increasingly coercive measures when perceived to have failed to do so. Consequently, biomedical orientations were remobilized in practice in spite of a purported shift in policy discourse towards more socially inclusive approaches. The term ‘biomedical residualism’ is coined to describe this phenomenon. However, instances of ethical professionalism that reflected resistance to these residualized modes of practice were also visible.

5.7 Adverse Childhood Experiences (ACE) Assessment in Integrated Child Mental Health

The research on adverse childhood experiences (ACEs), initiated by Vincent Felitti and Robert Anda, clearly shows the need to screen for and intercept child trauma exposure. Best practices regarding ACE screening in a pediatric clinical context remain unclear. Mental health services provided within integrated care models have been shown to provide positive health benefits for children and families facing adversities; however, ACEs are not generally used to guide these services. Our aim is to gain insight into the challenges and opportunities of using of ACEs to direct clinical and community mental health practice.

Building bridges between Puerto Rican psychology students and Massachusetts mental health clinics: Analysis of a workforce crisis

AbstractThe purpose of this article is to describe a field experience that used an applied psychoanalytic approach to discover potential unconscious barriers to attracting qualified Puerto Rican psychologists to work in western Massachusetts. The field experience involved a series of lectures at two Puerto Rican universities that train doctoral‐level psychologists. This field experience was conducted by Anglo internship professors and Puerto Rican doctoral psychology interns trained in Puerto Rico but interning on the mainland. Currently, there is a workforce crisis impacting mental health clinics that treat traumatized Puerto Rican families referred from child welfare and juvenile justice systems. The interns were training in the western Massachusetts city of Holyoke, which is 43% Puerto Rican. Holyoke is experiencing a crisis in its school system, which is 80% Puerto Rican students and is now under state receivership. This area in Massachusetts is in desperate need of Puerto Rican psychologists. The public schools are always seeking to work with outside agencies that can offer bi‐lingual and bi‐cultural clinicians.An applied psychoanalytic lens was utilized to analyze a cross‐cultural recruiting experience as a step in understanding the underlying dynamics that may contribute to a critical workforce shortage of Puerto Rican psychologists. The goal was to explore the fantasies and possible unconscious barriers of Puerto Rican doctoral students to move to the US mainland to practice in community mental health. The experiences analyzed two rounds of yearly discussions with (a) psychology students from two universities in Puerto Rico, (b) Anglo internship professors and (c) Puerto Rican interns who were already training on the mainland. Informal discussions with staff and recruited students after lectures provided the experiences to analyze. In the spirit of applied psychoanalysis this project used ideas from two psychoanalytic theories to explore concrete options to help improve the psychological journey of psychologists from Puerto Rican universities to the streets of Massachusetts. Barriers included fantasies about language, lack of experience with the “tools” of psychology (Electronic Health Records), weather, and inadequate planning for the migration experience. Areas for building bridges included offering courses to island training, such has electives for island psychology students thinking of migrating, shared internships with mainland and island universities, and collaboration in researching prevention models. The goal of this project was to uncover students’ fantasies about migration and develop an outline for discussion and training curricula of island psychology graduate students and mainland universities.