Community Mental Health Practice Research Articles

Community mental health nurses, caseloads, and practices: A literature review

Deinstitutionalization, and more recently, earlier discharges from psychiatric inpatient units, have created and intensified the need for case management in community mental health. Nurses have been at the forefront of providing this case management. This literature review provides a synthesis of research and policy on the contribution of mental health nurses to community case management. The focus of this review is on the proportion of case management that mental health nurses undertake, the caseloads of case managers, and the interventions that mental health nurses most frequently perform in the community. The professional compositions of mental health case management workforces have been associated with economic imperatives, professional priorities, and the choice of case management models. The influence of mental health nurses in the case management workforce is particularly strong in the U.K. and Australia, but less so in the U.S.A. where social workers and people without mental health qualifications perform similar roles. Although heavy caseloads seem to be common among case managers, the research in this area is quite weak. The interventions that mental health nurses perform most often include case management (e.g., coordinating care), counselling, and medication management. Caring for the physical health of consumers might often be overlooked.

A Working Relationship Model That Reduces Homelessness Among People With Mental Illness

We applied grounded theory methodology to generate a working relationship model that influences motivation for stable housing among homeless people with serious mental illness, to understand the role of a working relationship in critical service transitions. We focused on practitioners' perspectives and practices in Critical Time Intervention (CTI), a community intervention aimed to reduce homelessness through providing support during the transition from institutional to community living. We found a working relationship that highlighted "nonauthoritative" and "humanistic" features. Workers respected client autonomy and maintained flexibility in the format of client contact and service activities. They used practice strategies including following client leads and informal relating approaches to facilitate the development of client trust. The trusting relationship enhanced client interest in obtaining housing and the commitment to the transformation crucial for retaining housing. We discuss the significance of the relationship and ethical considerations of relationship-building activities in community mental health practices.

COPE for the Treatment of Depressed Adolescents

Despite a U.S. prevalence of 9%, less than 25% of depressed adolescents receive evidence-based treatment. To describe lessons learned from implementing the COPE (Creating Opportunities for Personal Empowerment) program in a community mental health practice as part of an evidence-based practice change to improve an advanced practice psychiatric nurse's clinical practice and provide treatment for depressed teens. A preexperimental one-group pre- and posttest design was used to assess the feasibility and effects of a brief manualized seven-session cognitive-behavioral skills-building intervention titled COPE delivered to 15 depressed adolescents in routine 30-minute mental health medication management outpatient visits. Applying the evidence-based practice model led to improved adolescent outcomes. Adolescents reported significant decreases in depression, anxiety, anger, and destructive behavior as well as increases in self-concept and personal beliefs about managing negative emotions. Challenges (limited organizational resources) needed to be addressed to implement the advanced practice psychiatric nurse's evidence-based practice change. COPE is a promising brief cognitive-behavioral therapy-based intervention that can be delivered within 30-minute individual outpatient visits. With this intervention, advanced practice nurses can work with current practice limitations and still provide evidence-based treatment for depressed teens. Collaboration between research-focused and clinically based nursing colleagues is a model of clinical scholarship that holds great promise in bridging the gap between research and practice.

Understanding Change in Community Mental Health Practices through Critical Discourse Analysis

Understanding Change in Community Mental Health Practices through Critical Discourse Analysis

Early Intervention for Substance Abuse Among Youth and Young Adults with Mental Health Conditions: An Exploration of Community Mental Health Practices

This mixed method study examined current practices and barriers for screening and assessing substance use among youth/young adults in community mental health systems. Substance use rates remain high among youth/young adults in the general population and substance use disorders are prevalent among young people involved in public service systems such as mental health. In an effort to understand the dynamics for early intervention, 64 case managers and/or clinical directors from children's mental health systems in two states participated in an online survey or focus group in fall 2008. Quantitative survey questions and qualitative focus group questions explored attitudes and perspectives about screening and early intervention for substance use among youth/young adults involved in the mental health system and current agency practices. Mixed method results suggest a number of barriers to substance use screening and early intervention and point to innovations that could be more effectively supported.

Mental Health Care in the Aftermath of Deinstitutionalization: A Retrospective and Prospective View

This paper offers a panoramic assessment of the significant changes experienced by psychiatric care in Western Europe and North America in the course of the last decades of deinstitutionalization and reform. Drawing on different comparative studies and an own review of relevant data and reports, the main transformations in the mental health field are analyzed around seven major topics: the expanding scope of psychiatry; the decline and metamorphosis of the asylum; the introduction of alternative and diversified forms of care; the new challenges posed by chronic mental illness; the emergence of modern psychopharmacology; the deployment of subspecialization; and the new forms of coercion implemented with community mental health practices. Following a renewed diagnosis on the essential features of the reformed mental health systems based on the pattern of social inclusion inherent to the new devices and philosophies of care, some major challenges for the future such as the overburdening of services or the overt exclusion of a significant part of potential users are also identified and briefly discussed.

Action Brief: Future Directions in the Implementation of Evidence Based Treatment and Practices in Child and Adolescent Mental Health

There has been an increased interest in recent years in understanding how to implement evidence-based practices/ treatments (EBP/Ts) in community settings (Insel 2009; Proctor et al. 2009), there still remain significant progress to be made in understanding this process of ‘‘transporting EBP into community settings.’’ Furthermore, there exists a considerable gap between the real practice of community mental health and the use of these effective programs. Over time, the studies and experiences of transporting will yield invaluable information, which in turn will increase our understanding and improve the implementation of effective practices into the community setting. However, these studies are unlikely to overcome the philosophical barriers to the implementation of effective programs. In fact, if effective practices are to reach the children, adolescents, and families who struggle with mental health problems, it is important that the field find a way to build bridges across the gap between researchers and practitioners in such a way that we improve the implementation and use of EBPs in community settings. Our focus here is threefold; to define the more ‘‘actionable’’ challenges and steps that will add to implementation studies; to further the improvement of effective practices; and to identify some of the potential action steps and possible solutions that will facilitate the implementation of EBP into community settings.

Legislation of Evidence-Based Treatments in Public Mental Health: Analysis of Benefits and Costs

The 2003 Texas 78th Legislature passed a bill that implemented several strategies to help realize a $1 billion decrease to health and human services spending (Senate Research Committee, 2003). A component of House Bill (HB) 2292 aimed at cost savings was the requirement for implementation of a resiliency and disease management model of service delivery in public mental health. As operationalized by the newly formed Department of State Health Services, the result was the legislation of evidence-based practice in community mental health in Texas. The purpose of this paper is to examine and analyze the policy change requiring a resiliency and disease management model for children's public mental health in response to HB 2292.

‘When you are tired or terrified your voice slips back into its old first place’: The role of feelings in community mental health practice with forensic patients

This paper explores the role of feelings experienced by professionals in community forensic practice. A modified grounded theory approach was used to conduct an analysis of transcripts made from five individual semi-structured interviews with multi-disciplinary professionals working in community mental health teams. The participants were asked to reflect on their feelings when working with forensic patients in the community and the extent to which they believed these feelings could influence professional practice. The following codes were established: emotional responses; binary thinking; deconstructing labels; bureaucratic defence procedures; practice dilemmas; the professional is personal; applying the therapeutic model to the practitioner; trauma; fantasy and imagination. As well as illustrating the significant impact that feelings have upon forensic practitioners, this paper also makes some suggestions to improve future practice. These include the use of psychoanalytic theory and ‘mindfulness’ strategies to enhance the awareness of mental health professionals regarding the influence of feelings upon practice.

Service-user and carer perspectives on compliance and compulsory treatment in community mental health services

This paper reports on a qualitative study analyzing service-user (SU) and carer perspectives on medication compliance and their experience of compulsory treatment. Eleven SUs and eight carers were interviewed. The research is set against the background of changes to mental health legislation in England, in the form of Supervised Community Treatment. This signals a change in community mental health practice and urges a reconsideration of concepts such as compliance, concordance and coercion. These concepts are discussed in the context of legislative changes and in relation to the perspectives of service-SUs and carers. Five themes emerged from qualitative interview data, analysed using an adapted form of grounded theory: loss of credible identity, playing the game, medicalization, therapeutic competence and incompetence and increased control. The findings suggest that SUs are initially reluctant to comply with mental health treatment, but do eventually accept the need for treatment; they also stress the significance of respectful relationships with professionals and the importance of communicative competence.

Risk and new exclusions in community mental health practice

Over the past two decades, mental health practice has become increasingly focused on assessing and managing the risks posed by service users. British researchers have made significant advances in studying the consequences of risk management for community-based health and welfare services, but in Australia this field remains largely undeveloped. Drawing on my experiences as a social worker in a Melbourne-based Crisis Assessment and Treatment Team from 1991 to 2008, the present paper offers a reflective analysis of the shift in practice orientation that has emerged through the growing prominence of risk as a foundation for intervention. Specifically, I argue that this shift has led to a narrowing of service provision and that “low-risk” clients are newly disadvantaged, often excluded from service.

Occupational Therapy and Care Coordination: The Challenges Faced by Occupational Therapists in Community Mental Health Settings

There is continuing debate concerning the role of occupational therapists within community mental health practice. This opinion piece advocates the need for occupational therapists to undertake more profession-specific work. Its argument draws upon real life case studies as well as the service users' views expressed in the recent College of Occupational Therapists' 10-year strategy for occupational therapy mental health services.

Public-Academic Partnerships: Research in Community Mental Health Settings: A Practicum Experience for Researchers

Applying research findings to community mental health practices is slowed by provider concerns that research participants often differ from community populations in duration of illness, comorbid conditions, and illness severity. Selecting participants from community settings makes research results demonstrably relevant, but researchers and community providers can be mistrustful of one another, feeling that the other has little understanding of their needs and work. This mistrust impedes patient referrals for research. This column describes a program to increase researcher knowledge of community clinic procedures through structured interactions with clinic personnel. Follow-up interviews indicate improved attitudes and cooperation of researchers and community providers.

Public-Academic Partnerships: Research in Community Mental Health Settings: A Practicum Experience for Researchers

Applying research findings to community mental health practices is slowed by provider concerns that research participants often differ from community populations in duration of illness, comorbid conditions, and illness severity. Selecting participants from community settings makes research results demonstrably relevant, but researchers and community providers can be mistrustful of one another, feeling that the other has little understanding of their needs and work. This mistrust impedes patient referrals for research. This column describes a program to increase researcher knowledge of community clinic procedures through structured interactions with clinic personnel. Follow-up interviews indicate improved attitudes and cooperation of researchers and community providers.

Gender, Suicide, and the Sociocultural Context of Deliberate Self-Harm in an Urban General Hospital in Mumbai, India

Recognizing the complementary effects of social contexts and psychiatric disorders, this study clarifies the role of gender in suicidal behavior in urban Mumbai by considering psychiatric diagnoses and patient-identified sociocultural features. The cultural epidemiological approach suggests the critical impact of situational sociocultural factors that complement the customary psychopathological accounts for those who harm or kill themselves. The cultural epidemiology of deliberate self-harm (DSH), it is argued, is critical to planning for suicide prevention, community mental health and psychiatric practice. This study, based on a cultural epidemiological framework, compares male and female admissions for DSH, evaluating conditions with SCID-I and EMIC interviews. We assessed features and narratives of suicidal behavior, patient-identified underlying problems, their perceived causes and triggers. The study included 92 women and 104 men. A diagnosis of depressive disorder was made for 48.9 percent of women and 39.4 percent of men. Many patients (50.0 percent of women and 41.3 percent of men) did not fulfill the criteria for any diagnosis, or did so only for an adjustment disorder or a V-code. Men typically explained DSH with reference to work problems, financial problems and problem drinking. Women typically discussed domestic problems, in-law relations and victimization. Problem drinking affected women living with men who drank. Social and situational factors appear to play a relatively greater role than psychiatric illness in self-harm and suicide in Mumbai, as in other Asian studies, compared with Europe and North America.

Diagnostic, Symptom, and Functional Assessments of Hispanic Outpatients in Community Mental Health Practice

With increased US Hispanic diversity come diagnostic challenges associated with culture, language, and expression of mental disorders. In a community-based clinic, we compared diagnostic agreement between Hispanic and non-Hispanic clinicians, and a structured diagnostic instrument, in live and videotaped interviews with Hispanic adults. Percentage agreement and kappas show low diagnostic reliability between clinicians, and between clinicians and instrument. Significant differences appeared in rates of various diagnoses. Non-Hispanic clinicians rated patients' functional capacity and symptom-severity as significantly worse than Hispanic clinicians. Findings match past research with Hispanic patients and raise questions about diagnostic reliability in multi-cultural community mental health practice.

Chapter 11.

This chapter presents answers to the twenty questions asked at the beginning of this volume, articulates a number of generally poor current practices of pharmacotherapy, makes suggestions for improvement in treatments combining medication and psychotherapy, and proposes important research at colleges and universities to gain understanding of use and misuse of psychotropic medication. We suggest that institutions of higher learning are primary places to reform and improve mental health services and are among the best proponents of community mental health theory, practice and research.

The Need to Adapt Standardized Outcomes Measures for Community Mental Health

SUMMARY In order to determine whether evidence-based practices are effective in community settings, the use of measurement tools that accurately capture symptoms and functioning in the community context is imperative. Without accurate measurement, researchers face the troubling possibility that tests of effective treatments may not attain positive results because of measurement error. The authors have experienced apparently serious problems with measurement validity in community mental health practice settings in which we are conducting diffusion research. Features of survey design that strengthen measurement in the university setting (where survey instruments are designed and treatments are usually tested) appear to work against us in community settings. Problems are compounded when it is necessary to measure across several domains, and thus, to employ multiple questionnaires. Here, we discuss the problems we have experienced with three common survey design strategies: (1) the use of multiple, similar items; (2) the use of reverse-coded items; and (3) the use of graded response-items. These strategies result in measures whose length and cognitive complexity may compromise their validity in community settings. Race is an especially important issue in diffusion research, as we lack even basic information concerning efficacy and effectiveness for some important evidence-based treatments. Invalid measures could seriously delay transfer and development of appropriate treatments. Careful psychometric work is badly needed, but such work is time intensive and costly. In the meantime, we encourage researchers to consider the modifications suggested here.

Sustaining a Focus on Occupation in Community Mental Health Practice

Occupational therapists working in community mental health teams (CMHTs) are often challenged to justify their unique approach to health through occupation, within an environment that tends to press for generic working. Such a challenge requires practitioners to identify and communicate evidence that supports their unique occupational contribution. In the absence of extensive robust and relevant research evidence, it is suggested that the contribution of theoretical evidence be considered. This paper, therefore, explores the potential of occupational justice and its related concepts to provide the profession with a theoretical justification for occupational therapists adopting an occupation-focused role in CMHTs. It begins with an overview of how CMHTs, generic working and occupational science have evolved. The concept of occupational justice and its related occupational risk factors are then analysed in relation to practice. The potential conflict between the professional commitment to client-centred practice and the generic worker model is also discussed. The paper concludes with recommendations for further exploration and consideration.

Development of a brief screen for substance misuse amongst people with severe mental health problems living in the community

Background: The only specific screening tool for substance misuse by people with severe mental health problems is the Dartmouth Assessment of Lifestyle Instrument (DALI), which was not developed for use amongst community-based people.Aim: To use the DALI to develop a brief community screen to detect the possibility of harmful substance use (N = 216 people with psychosis).Method: Anglicized versions of the DALI (DALI-UK), and the DALI adapted to accommodate changing patterns of drug use (DALI-MOD) were validated against criterion measures of substance misuse. Data from 160 patients were analysed to find which items best predicted problematic alcohol and drug use. A validation group (n = 56) was used to evaluate the scoring system and develop a short version.Results: Using logistic regression, a single item predicted our criterion measure for alcohol problems and two items predicted our criterion measure for drug problems. We developed the Simple Substance Use Screening Scale (SUSS), which correctly classified 86% of participants for problematic alcohol use (sensitivity 88%, specificity 84%) and 84% for problematic drug use (sensitivity 82%, specificity 84%).Conclusion: Because of its brevity and simplicity, SUSS would be a useful screen for use in routine community mental health practice.