Complex Mental Health Difficulties Research Articles

“Friendly, local and welcoming” – evaluation of a community mental health early intervention service

PurposeHalf of adulthood mental health challenges begin by the age of 14-years-old, making the need for early-intervention clear. This study aims to evaluate a new service model that promotes early-intervention through a community based low-intensity Hub.Design/methodology/approachClinical data from 2,384 young people were analysed through within-group, pre- and post-comparisons and qualitative survey, and interview data was analysed through content analysis.FindingsOverall, participants reported that they were highly satisfied with the Hub and the low-intensity brief interventions met their needs. Participants reported that learning new skills, having a place to talk and positive therapeutic relationships were beneficial. The Hub appeared to be less successful for young people with complex mental health difficulties. As a service, the adoption of the Hub model reduced waiting list times by more than half.Research limitations/implicationsThe quantitative data demonstrated that engaging with the Hub reduced symptoms of psychological distress. Qualitative analyses suggest that access to local, community, welcoming and “less clinical” support was beneficial, and the type of brief interventions offered was less important than therapeutic relationships.Originality/valueThis is the first study of a novel “Hub” model for low-intensity brief interventions in a socio-economically deprived area of England. Local knowledge, community integrated support, therapeutic relationships and a welcoming environment were viewed as more beneficial than the type of brief interventions offered. Consequently, community spaces can be created to be therapeutic and beneficial for mental health outside of a traditional conceptualisation of clinical support.

Schematic beliefs, negative affect and paranoia in at-risk youth.

Attenuated symptoms of psychosis are a core feature of At-Risk Mental States. However, subthreshold levels of paranoia are also common among nonpsychosis populations. At present, little is known about whether the processes underpinning the experience of paranoid ideation in high-risk youth differ as a consequence of meeting At-Risk Mental States (ARMS) for psychosis criteria. This study utilized path analysis techniques to examine the relationships between schematic beliefs, negative affect and the experience of paranoia for two groups: a group meeting criteria for ARMS (n=133) and a group presenting with emerging complex mental health difficulties who did not meet the criteria for ARMS (n=137). While the ARMS group displayed significantly greater maladaptive schematic beliefs and more severe symptomatology, the associations between schematic beliefs, symptoms of negative affect and paranoia did not differ as a consequence of ARMS status. While meeting the ARMS criteria is associated with experiencing more maladaptive cognitions and more negative symptomatology among at-risk youth, the associations between these cognitive beliefs and symptoms may be similar for youth who do not meet ARMS. These findings have implications for broadening the scope of at-risk/high-risk and for developing effective interventions for young people presenting with emerging difficulties.

Expanding arts therapies provision: a pilot project in Older Adult Mental Health Services, Aneurin Bevan University Health Board

ObjectivesThe aim of the report is to summarise the progress made during a six-month pilot project expanding arts therapies provision from an inpatient service to community services, in a National Health Service health board's Older Adult Mental Health Services, in response to the need for direct therapy with older adults who have severe cognitive impairment and communication difficulties arising from dementia and/or complex mental health difficulties. Study designThis is a case report on a pilot project. MethodsThe level of need for the service was explored, and indicators of effectiveness were gathered using evaluation forms—observer feedback forms and ARM-5 (Agnew Relationship Measure - 5) - to indicate the therapeutic alliance, team review and feedback from colleagues. ResultsTo gather indications about the level of need, we recorded the following: number of referrals (n = 125) and waiting list numbers at the end of the project (n = 34). ConclusionsThis pilot project indicates that there is need for psychological interventions in older adult community mental health services that arts therapies provision can help address. The number of referrals is one indicator of the level of need, and positive feedback from clients, families and colleagues, is an indicator that the team delivered effectively. The areas of client need addressed in sessions as documented in observer feedback forms indicate that for these clients, arts therapies was a valuable resource in addressing challenges arising from mental health difficulties and/or dementia.

Psychological recovery in a step 4 service: a qualitative study exploring the views of service users and clinicians

Background Psychological recovery is typically measured in improving access to psychological therapies (IAPT) services as the reduction of symptoms on routine outcome measures (ROMs). However, conceptualisations of psychological recovery vary, and there are concerns that ROMs may not be suitable for measuring recovery from complex mental health difficulties. Aim To gain insight into psychological recovery and measurement in clinical practice. Method A qualitative study at a step-4 IAPT service in the North of England. Eight clinicians contributed to focus groups, and 10 service users were later interviewed individually. Results Factors that informed four congruent and interacting themes of recovery were identified among participants as an ongoing personal process, of intra-therapeutic and extra-therapeutic factors impacting on recovery in helpful and unhelpful ways, and the need for idiographic long-term recovery measures. The functional and long-term nature of recovery and the socio-economic context for recovery were considered particularly crucial. Conclusions The need for idiographic long-term recovery measures to support the ongoing process of recovery was reported in the majority of instances. Study findings mirrored existing recovery and outcome measurement literature, provided new evidence in relation to recovery from complex mental health difficulties, and made recommendations for future research and clinical practice.

The impact of therapeutic endings on therapists who deliver time-limited therapy with clients with complex mental health difficulties: A thematic analysis

For the purpose of this service evaluation, therapists were interviewed about their experiences of ending therapy within a time-limited setting. Three over-arching themes were identified showing the ways in which therapists are impacted by therapeutic endings.

Experiences of receiving cognitive analytic therapy for those with complex secondary care mental health difficulties.

Service users with complex mental health difficulties are more difficult to engage in treatment and drop-out rates are higher, resulting in poorer clinical outcomes. Cognitive analytic therapy (CAT) is widely applied to service users with complex needs and shows promise in terms of engagement and outcomes. The aim of the present study was to examine the 'lived experience' of service users who have been retained in a full course of CAT treatment to provide important insights to why CAT seems to be an engaging psychotherapy, to inform future CAT delivery and practice with clients with complex needs. Semi-structured interviews were undertaken with six service users aged between 25 and 47years who had accessed secondary mental health care services and had received an average of 24 sessions of CAT. Transcripts were analysed using interpretative phenomenological analysis (IPA). The analysis yielded three superordinate themes with subthemes within these. The first superordinate theme referred to changes due to CAT (e.g., insight, tools to cope). The second theme referred to strong emotions evoked by CAT (e.g., feeling frustrated, scared, and upset). The final theme concerned the process of CAT (e.g., endings and therapeutic relationship). Whilst service users appeared to develop increased insight and acquire skills, there was variance in experiences of sustained and meaningful change post-therapy. The findings suggest adaptations may be required with these service users such as delivering the sequential diagrammatic reformulation (SDR) in a hopeful way and addressing systemic barriers to 'exits' being made. Overall, service users with complex mental health difficulties describe benefitting from CAT, identifying improved insight and the acquisition of tools to cope. However, therapists need to be attuned to the potential fragility of service users and risk of negative affect, particularly during the reformulation phase. Consideration of delivering the SDR in a hopeful way may be therapeutic. Systemic factors such as service users being pulled to maintain the status quo in their relationships, and lack of support for or resistance to change by important others limit service users from availing of 'exits' from problem procedures. This implicates the need for more attention to systemic and possibly multi-agency working with this group of service users.

New models of care in general practice for the youth mental health transition boundary.

Mental illness represents the highest proportion of disease burden for children and young people in the UK.1 However, despite this, young people can struggle to access timely and appropriate mental health care. One particular barrier to continuity of care occurs when young people reach the upper age limit (usually 18 years) of child and adolescent mental health services (CAMHS). If they require ongoing specialist support, their care should be transferred to an adult mental health service (AMHS), through a purposeful and planned transfer of care known as ‘transition’. However, only around a quarter of young people transition to AMHS,2 and in the absence of specialist adult mental health care, GPs often become involved in the young person’s care ‘by default’.3 Although GPs become responsible for the young person’s care after they leave CAMHS, they may not have the necessary skills and resources to manage complex mental health difficulties in young people. ### The role of the GP in transition The National Institute for Health and Care Excellence (NICE) transition guidance calls for a named GP to be part of the transition process, emphasising the role GPs can have in continuity of care.4 The guidance states that the person acting as the ‘named worker’ (who is responsible for coordinating transition for the young person) should proactively engage GPs in transition planning, allowing GPs to be involved in the young person’s mental health care at this crucial stage. At present, however, there is no known evidence to suggest that GPs are regularly involved in transition planning. This may be due to differing organisational cultures which prevent collaborative working; something which has been identified as a barrier …

An exploration of group-based compassion-focused therapy for adolescents and their parents.

Background:The long-term negative consequences of mental health problems during adolescence highlight the need for effective treatments. Compassion-focused therapy (CFT) aims to help individuals to enhance their ability to support and care for themselves and to alleviate shame and self-stigmatization.Objective:This non-randomized controlled trial examined the effectiveness of group-based CFT on perceived stress and the extent of self-compassion in a clinical sample of adolescents receiving psychiatric care for complex mental health difficulties and their parents.Method:The participants were 43 adolescents (ages 14–17; 83.7 % female) under treatment at a child and adolescent psychiatric outpatient clinic in Sweden and their parents (n = 77; 61 % female). The adolescents volunteered for group-based CFT (n = 19); if they did not want to participate, they were asked to join the control group receiving treatment as usual (TAU, n = 24). The CFT parents were given the same treatment as their children in parallel parent groups. The participants completed questionnaires measuring self-compassion and perceived stress before and after treatment. Paired samples t-tests and independent samples t-tests assessed the within-group and between-group differences via change scores.Results:The fathers scored highest on self-compassion and had less perceived stress at both times than the adolescents or mothers. There were no significant differences between the CFT and TAU groups in self-compassion or perceived stress at either time, and the effect sizes were small (g ≤ 0.25). The TAU mother group was the only group with a significantly changed mean self-compassion score post-treatment.Conclusions:Some patients seem to benefit from group-based CFT in ways similar to the benefits of specialized therapeutic approaches. Further research into the utility of CFT for adolescents with MH problems and their parents, as well as the long-term clinical effects of CFT for this group is needed.

A qualitative evaluation of an ACT-based substance misuse treatment programme for service users within a secure mental health setting

Purpose The purpose of this paper is to understand service users’ experience of a new acceptance and commitment therapy (ACT)-based substance misuse programme. The programme is designed for people in secure mental health services, presenting with complex mental health difficulties and co-occurring substance misuse problems. Design/methodology/approach A qualitative approach informed an exploratory pilot of this novel intervention. Service users completing a 16-week ACT programme were invited to participate in the current study. Out of the nine individuals enroled on the programme, six opted to take part in the exploratory pilot and completed semi-structured interviews following part 1 of the programme (eight weeks). Four of these participants proceeded into part 2 of the programme (eight weeks) and completed a further semi-structured interview. Findings The thematic analysis identified five main themes: “Increased awareness of personal values and the impact of substance use on values”, “Taking committed action towards values”, “Coping skills and the application of skills to manage difficult thoughts and feelings”, “Personal development” and “Use of metaphors/analogies”. Research limitations/implications A quantitative evaluation of clinical outcomes is recommended to gauge further programme effectiveness. Practical implications The findings provide preliminary support for the use of an ACT-based substance misuse programme in a secure mental health setting. Originality/value This study evaluates the use of a novel ACT-based substance misuse intervention with people in secure mental health care with co-occurring mental health and substance misuse difficulties. This paper provides an in-depth understanding of service users’ experience of participating in this new treatment programme.

Flexing the frame: therapist experiences of museum-based group art psychotherapy for adults with complex mental health difficulties

ABSTRACTThis research aimed to investigate our experiences of facilitating museum-based art psychotherapy groups for adults with complex mental health difficulties, identifying key themes to help inform the practice of other art psychotherapists working in museum settings. Drawing on concepts of tacit knowledge, action research, reflexivity and arts-based research, we engaged in structured discussions and reflective art-making in three areas of focus, and then carried out a simple thematic analysis of the data. The areas of focus were: the role of museum objects within the art psychotherapy process; the movement between and within the private artmaking space and the public spaces of the museum; and the potential impact of the public nature of the museum. The themes we identified relate to familiar theoretical concepts such as containment, mentalisation, transitional objects and space, attachment and joint attention. Our research led us to challenge our feeling that we were ‘breaking the rules’ of ‘orthodox’ group art psychotherapy practice by working outside the framework of a traditional therapy room. We conclude that there is potential value in this particular way of ‘flexing’ our practice and encourage other art psychotherapists to explore museum-based work and share their experiences.Plain-language summaryThis article explores the issues involved in running art psychotherapy groups for people with long term mental health difficulties in museums instead of NHS outpatient centres. It is written from the perspective of three art psychotherapists who examine their own experience of running these types of groups. The research gives insights into the opportunities and challenges of working in this way.We started by agreeing on three specific questions: what significance might the museum objects hold for the service users, how might physically moving between a private art-making room and the public space of the museum impact on the service users, and what are the potential issues involved in delivering art psychotherapy in a public building rather than the more private space of an NHS building?For each of the three areas we met twice. At the first session we discussed our experience of running the museum-based groups in relation to that area, and at the second we used artmaking to expand our discussion. We recorded and transcribed our discussions and analysed the transcripts. The analysis produced several themes, which we then related to existing psychotherapeutic theory. We used a simple research process that helped us to think about what we do as art psychotherapists and why - a process which other art psychotherapists could use for their own research.We conclude that there are different issues and opportunities when working in museums compared with working in NHS buildings. The work challenges traditional expectations of how art psychotherapy is carried out and requires creativity and flexibility on the part of the therapist. We found that using museums for art psychotherapy was an interesting and valuable extension to our work. Other art psychotherapists who wish to run groups in museums may find our insights useful.

Whose Responsibility is Adolescent\u2019s Mental Health in the UK? Perspectives of Key Stakeholders

The mental health of adolescents is a salient contemporary issue attracting the attention of policy makers in the UK and other countries. It is important that the roles and responsibilities of agencies are clearly established, particularly those positioned at the forefront of implementing change. Arguably, this will be more effective if those agencies are actively engaged in the development of relevant policy. An exploratory study was conducted with 10 focus groups including 54 adolescents, 8 mental health practitioners and 16 educational professionals. Thematic analysis revealed four themes: (1) mental health promotion and prevention is not perceived to be a primary role of a teacher; (2) teachers have limited skills to manage complex mental health difficulties; (3) adolescents rely on teachers for mental health support and education about mental health; and (4) the responsibility of parents for their children’s mental health. The research endorses the perspective that teachers can support and begin to tackle mental well-being in adolescents. However, it also recognises that mental health difficulties can be complex, requiring adequate funding and support beyond school. Without this support in place, teachers are vulnerable and can feel unsupported, lacking in skills and resources which in turn may present a threat to their own mental well-being.

Shining lights in dark corners of people's lives: Reaching consensus for people with complex mental health difficulties who are given a diagnosis of personality disorder.

Shining lights in dark corners of people's lives: Reaching consensus for people with complex mental health difficulties who are given a diagnosis of personality disorder.

An Exploration of People's Experiences of Compassion‐focused Therapy for Trauma, Using Interpretative Phenomenological Analysis

Self-compassion enhances psychological well-being, and compassion-focused therapy aims to alleviate psychological distress by fostering its development. The experience of becoming self-compassionate for people with complex mental health difficulties has not been analysed in the literature, despite clinical observations that this process is difficult. This study explored the process of becoming self-compassionate for people with posttraumatic stress disorder, using interpretative phenomenological analysis. Semi-structured interviews were conducted with seven participants. Five superordinate themes emerged from the data including: (1) the battle to give up the inner critic: who am I if I am not self-critical?; (2) an aversive and alien experience: how it feels to develop self-compassion; (3) the emotional experience of therapy; (4) self-compassion as a positive emotional experience; and (5) a more positive outlook in the present and for the future. Self-criticism formed an important part of the participants' self-identity, and they experienced an initially aversive emotional response to self-compassion, describing it as a completely new experience and one to be feared. Despite this, they were able to persist with therapy and subsequently experience positive emotional responses to self-compassion. They reported the therapeutic relationship as an important factor making this possible. Participants reflected on several reasons for the aversive nature of developing self-compassion, which are discussed. A process model of the journey from self-criticism to self-compassion is proposed. It is suggested that the obstacles frequently experienced when developing self-compassion can be overcome, instilling hope for both therapists and clients.

Autistic spectrum disorder, personality disorder and reading disability: a complex case that falls between the cracks?

This case report describes an individual convicted of a violent offence whose complex mental health difficulties appear to be a reason for excluding him from services. During the individual’s admission to a specialised service for personality disorder, a range of structured and semi-structured assessments identified an array of psychological difficulties. Clinical formulation was informed by a contemporary evidence-based typology and suggested that his violence was characterised by anxiety and vengeful/ruminative anger. The fact that the individual’s needs were multiple – including autism, personality disorder, dyslexia and a rare neuropsychological profile – paradoxically appeared to be a reason for mental health services not to intervene, so that he continues to languish in prison. As forensic services in the future are likely to be required to provide for an increasingly difficult clientele, this case highlights not only potential deficiencies in current forensic mental health provision, but the challenges that services are likely to face in the future.

Do we miss depressive disorders and suicidal behaviours in clinical practice?

This study involved a detailed standardized initial research assessment which was carried out with 100 young people aged 12-15 years newly referred to a child and adolescent mental health service. The assessment involved the K-SADS interview with the young person and their parent, the Strengths and Difficulties Questionnaire, the Clinical Global Impression Scale, and the Children's Global Assessment Scale. Diagnoses resulting from these 'research assessments' were compared with clinical diagnoses, which were determined by case note analysis and discussion with the key clinician. Results showed that a clinical diagnosis of depressive disorder was made in only one-third of those who received a 'research assessment' diagnosis of depressive disorder, and suicidality was missed in a significant proportion of cases. Those with a diagnosis of depressive disorder had significantly more problems, more comorbidity, more suicidality and greater functional impairment than those without. It is important to keep depression and suicidality in mind when assessing young people with complex mental health difficulties. Unless specific pointers are sought, it is easy to miss these, which may mean that vulnerable young people do not benefit from potentially effective treatments.

The effect of inpatient care on measured Health Needs in children and adolescents

The concept of 'health need' relates patient problems in symptom and psychosocial domains to available appropriate treatments. We studied the effectiveness of inpatient treatment in modifying measured 'Health Needs' in children and adolescents admitted to UK inpatient units. A prospective cohort study of 150 children and adolescents admitted to eight UK inpatient units, using formal pre-admission, pre-discharge and 1-year follow-up measurement of Health Needs. Total patient 'Cardinal Problems' reduced highly significantly (p < .001) from 8.5 at admission to 5.7 at discharge (effect size .81) and to 4.1 one year after discharge (effect size 1.35). Functional domains free of 'Health Needs' increased from 14.9 to 19.4 (effect size 1.08) from the point of admission to the end of follow-up. These changes were clinically meaningful, present in all domains and reduced morbidity to a level typical of outpatient cases. Admission (mean length 116 days, SD 88) leads to clinically important improvement in measured Health Needs over multiple domains for children with serious, complex mental health difficulties. These improvements in multiple symptom and functional domains persist over the next year.