Community Mental Health Practice Research Articles

Developing a Comprehensive Understanding of the Working Alliance in Community Mental Health

The concept of a working alliance as a key ingredient within therapeutic processes has been emphasized by many community mental health researchers and practitioners. However, few studies have provided insights into the dimensions and operationalization of the concept. To address this gap, the authors analyzed data on the working alliance derived from two qualitative data sets: (a) interviews conducted with 33 users of community mental health services, family members, and service providers; and (b) content extracted from a systematic review of 48 articles in the area of community mental health services. Three superordinate themes emerged: Building and negotiating trust, I'm on your side, and Tools and strategies. The authors discuss implications for community mental health practice.

Community Psychiatric Practice

Community Psychiatric Practice is a specialsection within Community Mental Health Journal devotedto issues relating to psychiatrists who practice incommunity mental health centers and similar settings. The intent of the section is to stimulateinteraction and involve community psychiatrists andother community mental health professionals in adialogue analogous to the collaborative situation in thecommunity mental health center. Dialogue andcounter-point will be provided by responses from one ortwo other community mental health experts. Topics willinclude clinical issues, new treatment methods, special populations, training and education, andquestions regarding the role and function of communitypsychiatrists. Anyone wishing to submit articles forconsideration for Community Psychiatric Practice should contact Robert E. Drake, M.D., West CentralServices, Inc., 2 Whipple Place, Suite 202, Lebanon, NH03766.

Integrating Complementary Therapies into Community Mental Health Practice: An Exploration

To (1) describe the integration of massage and energy-based therapies with psychotherapy in a community mental health center, (2) to present qualitative feedback on the service, and (3) to present pilot data from a sample of long-term clients with persistent mental health concerns. A noncontrolled pilot study was conducted using interview data before and self-report instruments after completing a brief program of complementary therapy accompanying ongoing psychotherapy. The program took place at a comprehensive community mental health center in southern Maine and in the private offices of massage therapists and energy healing practitioners who contracted with the program. Subjects were 20 women and 5 men, with mean age of 42 years and a mean history of 7.4 years of mental health treatment. All had histories that included trauma, 10 of which involved sexual abuse. The Diagnostic and Statistical Manual of Mental Disorders IV Axis I diagnoses were PTSD (10), major depression (nine), anxiety disorder (three), and dual diagnosis (three). Clients receiving ongoing psychotherapy were assigned to one modality of complementary therapy based on clinical judgment, availability of practitioners, and client interest. Modalities used were massage, acupuncture, Reiki, and Healing Touch. The mean number of sessions was five. Clients completed an investigator-generated instrument with Likert-scaled ratings of satisfaction and perceived changes in four dimensions of trauma recovery: perceived interpersonal safety, interpersonal boundary setting, bodily sensation, and bodily shame. Clients reported high levels of satisfaction with the service and significant levels of perceived (self-rated) change on each outcome measure. Qualitative results included enhanced psychotherapeutic outcomes reported by mental health clinicians. The integration of complementary therapies into community mental health practice may hold promise of enhancing mental health outcomes and improving quality of life for long-term users of mental health services.

Early recoginition of dementia by nurses.

The early recognition of dementia has assumed an increasingly important place in primary care nursing. This paper reports a survey conducted in the context of a national programme of educational workshops on dementia which attracted almost one thousand participants. The subjects who answered the questionnaires included community mental health nurses (CMHNs), community nurses (CNs), and practice nurses (PNs). The results indicated that CMHNs were the most confident in their ability to recognise dementia and found it easier to provide appropriate support. However, it was also apparent that CNs in particular also had considerable contacts with some people with dementia. This highlighted the need for a team approach to dementia care in the community, with CMHNs taking the key co-ordinating role which previous studies had tended to allocate to the general practitioner.

Early recognition of dementia by nurses.

Early recognition of dementia is a key policy objective designed to maximize the efficacy of treatment and to provide timely and appropriate support before crisis occurs. The impact of early recognition of dementia is under-researched in primary care nursing. To explore whether community mental health nurses (CMHNs), community nurses (CNs) and practice nurses (PNs) have different perspectives on early diagnosis of dementia and to consider the possible effects of any variation. Data are drawn from questionnaires completed by CMHNs (79), CNs (153) and PNs (36) who attended workshops offered on 24 occasions in 21 settings across the United Kingdom. The workshops attracted a range of primary care practitioners and were part of a training programme on early diagnosis of dementia. Analysis of the data shows some differences in knowledge, experience and confidence between the three nurse groups. CMHNs were more confident in their abilities to recognize dementia and found providing support less difficult than CNs and PNs. CMHNs considered that they were best placed to co-ordinate services for people with newly recognized dementia. CNs and PNs, however, reported experience of working with people with dementia and many appeared able to respond to early signs and to identify potential sources of support. While CMHNs may have a key role in responding effectively to the newly identified needs of people with early dementia, other nurses working in the community are likely to encounter people with early dementia. In the context of a policy objective to identify people with dementia earlier, all community-based nurses should be able to recognize the possibility of dementia and support those undergoing referral or assessment. Their confidence in doing so should be enhanced by continued professional development. Training in dementia recognition, involvement in and membership of primary care teams supporting people with dementia should not be confined to CMHNs. Nurses who regularly encounter the general population of older people may be well placed to provide continuity of support for those who may, or may not, have cause to suspect that they or their relatives have early dementia.

Internship and Initial Job Placements in Counseling Psychology

A 26-year retrospective study was conducted on internship and initial job placements of counseling psychologists. The results indicated that university counseling centers consistently supported the highest percentage of the field’s predoctoral interns followed by Veteran Administration Medical Centers, other hospital settings, and community mental health centers. Initial job placements indicated relative parity among placements in academic, community mental health, counseling center, and private practice settings with Veterans Administration Medical Centers and other hospital settings accounting for significant percentages of the field’s initial job placements. In addition, changes in internship and job placements across time indicated that various contexts have waxed or waned in their contribution to the training and placement of counseling psychologists. Results are discussed in relation to the evolving identity of counseling psychology as a specialty and the contexts that support and challenge that development.

The context of care: Issues of power and control between patients and community mental health nurses

Issues of power and control are inevitably linked to the nurse–patient relationship within mental health settings. This paper discusses power relations between nurses and patients within the context of the home visit as an important component of the provision of care to patients living with enduring mental illness. An interpretive ethnographic account was adopted to explore how nurses and patients negotiated issues of power and control with respect to the specific responsibilities associated with community mental health nursing practice. The home visit involved a shifting of power in favour of the patient; patients behaved as ‘hosts’ and nurses as ‘guests’. However, within this framework, nurses still exerted power in relation to certain aspects of patients' daily living which are deemed to be within the domain of nursing, and so legitimise the nurse's interventions. This study explicates the daily exigencies of community mental health practice and provides insights into difficult aspects of nurses' work, which have received little attention in the nursing literature to date.

HIV-related services for persons with severe mental illness: Policy and practice in new hampshire community mental health

Rates of HIV and HIV risk behaviors are elevated among people with severe mental illnesses (SMI). Little is known about the extent to which community mental health (CMH) centers screen, refer, and educate their clients regarding HIV and sexually transmitted diseases (STDs). The authors surveyed CMH administrators and clinicians in New Hampshire regarding HIV/STD policy, practices, knowledge, and attitudes. HIV/STD service availability varied, and the amount of services provided was unrelated to the prevalence of HIV and AIDS in that region. Clinicians were knowledgeable about general HIV information but lacked specific knowledge about HIV related to persons with SMI. CMH staff had positive attitudes about helping clients with HIV issues. Administrators were interested in receiving training. Policy leadership, CMH practice guidelines, and training are warranted in light of the pressing public health implications of HIV/STDs among people with SMI.

A Delphi approach to describing service models of community mental health practice.

The activities of mental health practitioners are poorly understood and described because of a lack of generally accepted and understandable categories. Greater precision is needed for accountability, planning, and evaluation. The objective of this study was to identify a valid and reliable set of categories to describe the clinical work practices of intensive case managers in the United Kingdom. Eight intensive case managers participated in a Delphi process to produce a set of categories that described their clinical work practices. They each completed three questionnaires and participated in a final group discussion. The initial open questionnaire generated 38 potential categories after exact duplicates were removed. In round 2, the intensive case managers each rated the 38 categories from 1 to 5 (essential to unimportant). A high degree of consensus on the relative importance of the 38 suggested practice categories was rapidly achieved. In round 3, they re-rated the categories in the light of group medians and their own round 2 ratings. In a structured face-to-face discussion group, the intensive case managers then reduced the 38 potential categories to ten comprehensive and mutually exclusive categories that were judged to adequately and accurately reflect work practices. They were housing, finance, daily living skills, criminal justice system, occupation and leisure, engagement, physical health, caregivers and significant others, specific mental health intervention or assessment, and medication. Delphi methods were effective and relatively straightforward in producing an agreed-on set of categories with which to record clinical activity and inform care planning.

Dilemmas in Community Mental Health Practice: Choice or Control. By R. Perkins and J. Repper. (Pp. 151; £19.95.) Radcliffe Medical Press: Abingdon. 1998.

<i>Dilemmas in Community Mental Health Practice: Choice or Control</i>. By R. Perkins and J. Repper. (Pp. 151; £19.95.) Radcliffe Medical Press: Abingdon. 1998.

Specialist practice in community mental health nursing

Community mental health nurses (CMHNs) work in an increasingly complex health and social care environment. Over recent years, the evolving direction of general health service and specific mental health policy has directed CMHNs towards: the provision of clinically-effective interventions; a closer attention to meeting the needs of people experiencing severe and long-term mental health problems; the simultaneous provision of services to meet the needs of people experiencing a wide range of mental health problems presenting in primary care settings; greater collaboration with workers representing other disciplines and agencies; and the development of active partnerships with mental health service users.This paper explores the context within which CMHNs practise, and within which education programmes preparing specialist practitioners in community mental health nursing have been developed. One recently-validated specialist practice course for CMHNs is described in detail, with the intention of stimulating discussion and debate surrounding the practice of, and the educational preparation for, community mental health nursing.

The a-z of community mental health practice Graham Durcan The a-z of community mental health practice Stanley Thorne 152 £11.99 0-7487-3175-X 074873175X

Calling a book an A-Z is inviting trouble and that is what Sheila Forster has done. The problem is it makes it easier for the reviewer to spot gaps and - yes - there are some here. For example, community- based alternatives to admission are not really considered, nor is assertive outreach, educating clients and their carers about warning signs, triggers and symptoms.

Childhood sexual abuse: seeking meaning to traumatic experience

In exploring social role problems experienced by adult survivors of childhood sexual abuse, this paper seeks to examine their social construction of reality through phenomenological and symbolic interactionist perspectives. This paper considers the psycho-social formation of destructive patterns and self sabotaging behaviour and places childhood sexual abuse within a mental health context. It also addresses the particular problems facing community psychiatric nurses working with this client group and recommends a model of intervention that can be integrated into community mental health practice.

Learning in Context: Perceived Benefits of Fieldwork Education within Community Mental Health Settings

The emphasis on community-based services for people with psychiatric disorders requires a concerted response from occupational therapists, if we are to assist people to live meaningful lives in their own communities. This article draws on the fieldwork experiences of 16 Australian and American occupational therapy students, to reflect on fieldwork education and how it may be preparing students to meet the demands of proactive practice in psychiatry. Attention is drawn to the Importance of fieldwork education in community contexts for occupational therapy students, if these future therapists are to be adequately prepared for the demands of community mental health practice.

Special Education, School Psychology, and Community Mental Health Practice in Rural Settings: Common Problems and Overlapping Solutions for Training

Rural service delivery issues common to the fields of special education, school psychology, and community mental health are described within this article. Many problems common across the three disciplines have some parallel solutions, and a number of potential solutions are suggested. Given preparation at the preservice level appears to be an effective starting point for preparing practitioners to deal with specific problems, the focus of these training-based solutions is at the preservice training level.

The emotional experience of caregivers to relatives who are chronically confused—Implications for community mental health nursing

This paper examines the emotional experience of informal caregivers to family members who are chronically confused. Six informal caregivers were taken from the caseloads of community mental health nurses working with elderly people. Data were collected by means of a daily diary and in-depth interviews relating to their emotional experience as caregivers. The data are presented in the form of six vignettes and the implications for theory, practice and research in community mental health nursing are examined.

The role of general practice in community mental health: A survey in four districts of Copenhagen

The study describes the activities and referrals of general practitioners (GPs) in relation to patients with mental health problems in the early stage of the establishment of community mental health centres in Copenhagen. During a 2-week period 30 GPs completed a data sheet for each face-to-face contact with patients with mental health problems. Totally, 313 such contacts were reported, involving 271 patients. The commonest problems were neuroses and personality disorders. A clear sex difference was found in diagnosis patterns. One-third of the contacts were initiated by patients with a physical problem - more among the elderly than among younger patients. The duration of the contacts was rather short, but almost half of the contacts included an appointment for a follow-up visit. In more than one-third of the contacts the patients were referred to other services. When asked about unmet needs, the GPs most often mentioned the need for referring to a psychologist, whereas a community mental health centre or...

Community Mental Health Principles and Practice

Community Mental Health Principles and Practice

Rediscovering Welfare Concepts in Social Work Practice in Community Mental Health

The tension between concepts of welfare and treatment remains an important issue for social workers practising in the field of community mental health. A primary concern with treatment has resulted in a neglect of welfare issues. The social consequences of developments in community mental health, particularly the poverty and disadvantage accompanying the deinstitutionalisation movement, have resulted in an increased need for social workers to redirect energy towards meeting welfare needs, particularly income security and housing.

Boarding home residents: new underclass in the mental health system.

Boarding homes have proliferated in recent times, spawned by the deinstitutionalization movement. This study explored the realities of living in these homes by using a quantified assessment procedure to examine their programs and policies. Findings suggest an absence of support and stimulation for the residents of homes and a need for outreach and advocacy on the part of social workers in community mental health practice.