Mental Health Care Practice Research Articles

High variability of the current mental health practices around the globe: Twenty days in the lives of psychiatrists and other mental health care professionals from all over the world

Abstract Introduction The present is the future of the past, and the past of the future. This journal as well as this paper endeavour to document the lives and practices of psychiatrists and other mental health care professionals for the future mental health community and to help the clinicians of the future to understand the history and practice of psychiatry and mental health care in 2019/20. We, therefore, report the current days in the lives of psychiatrists and other mental health care professionals. Material and Methods To obtain reports of days in the lives of psychiatrists and other mental health professionals, we published the request on eight occasions from May 2019 to May 2020. We invited the prospective respondents/participants to send a relevant report of their psychiatric practice in a day with a maximum word count of 750 words. Results We received 20 reports of variable lengths from 10 countries from six continents, including from psychiatrists, psychiatrists in training, clinical psychologists and from medical students about their psychiatric training. The reports revealed a wide and highly variable range of psychiatric and mental health practices, experiences and expectations. Last but not least, the reports we received were informative and provided much information to reflect on. Conclusions There is a common strong commitment to support patients with mental health problems, but the ways this is achieved are so diverse that generalisations about a typical common practice seem impossible. Future studies should focus more systematically on the procedures and practices applied in helping patients with mental health problems in different countries and communities. This knowledge might eventually help identify the procedures and services that are most efficient and helpful in various clinical contexts.

Evaluation the Effectiveness of Family Intervention Targeted at People Diagnosed with Schizophrenia versus People Diagnosed with Schizophrenia and Family Caregivers: Findings from Integrated Systematic Review

Aims: This literature review examines the effectiveness of the family interventions (FIs) targeted at people diagnosed with schizophrenia and/or family caregivers on improving knowledge level of schizophrenia and health related outcomes. Methods: A total of 18 studies were reviewed from December 1999 to May 2015. The methods described by Centre for Reviews and Dissemination were used to guide this review. Results: The FIs showed consistently improvement in the knowledge level of schizophrenia among participants for various follow-up intervals. In addition, FIs were found to be superior to treatment as usual in influencing health related outcomes. Conclusions: Implications of the findings for mental health care practice to include primary caregivers with patient in treatment process.

Making change happen in criminal justice settings: leveraging implementation science to improve mental health care

BackgroundIt is a constitutional right to receive health care, including mental health care, while incarcerated. Yet, even basic evidence-based mental health care practices have not been routinely integrated into criminal justice (CJ) settings. Strategies from implementation science, or the study of methods for integrating evidence-based practices into routine care, can accelerate uptake of established interventions within low-resource, high-need settings such as prisons and jails. However, most studies of mental health practices in CJ settings do not use implementation frameworks to guide efforts to integrate treatments, systematically select or report implementation strategies, or evaluate the effectiveness of strategies used.Case presentationsAfter introducing implementation science and articulating the rationale for its application within CJ settings, we provide two illustrative case examples of efforts to integrate mental health interventions within CJ settings. Each case example demonstrates how an implementation framework either was applied or could have been applied to promote intervention adoption. The first focuses on poor implementation of a mental health screener in a county jail, retrospectively highlighting how use of a determinants framework (e.g., the Consolidated Framework for Implementation Research [CFIR]) could help staff identify factors that led to the implementation failure. The second describes an investigator-initiated research study that used a process framework (the Exploration, Preparation, Implementation, Sustainment [EPIS] framework) to systematically investigate and document the factors that led to successful implementation of a psychotherapy group for survivors of sexual violence in a women’s community corrections center. Both are presented in accessible language, as our goal is that this article can be used as a primer for justice health researchers, community partners, and correctional leadership who are unfamiliar with implementation science.ConclusionsScientific research on the application of implementation science to justice settings is growing, but lags behind the work done in health systems. Given the tremendous need for mental and behavioral health intervention across the full spectrum of justice settings, information on how to successfully implement evidence-based intervention and prevention efforts is sorely needed but possible to obtain with greater integration of knowledge from implementation science.

Efficacy of interventions to reduce coercive treatment in mental health services: umbrella review of randomised evidence.

Coercive treatment comprises a broad range of practices, ranging from implicit or explicit pressure to accept certain treatment to the use of forced practices such as involuntary admission, seclusion and restraint. Coercion is common in mental health services. To evaluate the strength and credibility of evidence on the efficacy of interventions to reduce coercive treatment in mental health services. Protocol registration: https://doi.org/10.17605/OSF.IO/S76T3. Systematic literature searches were conducted in MEDLINE, Cochrane Central, PsycINFO, CINAHL, Campbell Collaboration, and Epistemonikos from January 2010 to January 2020 for meta-analyses of randomised studies. Summary effects were recalculated using a common metric and random-effects models. We assessed between-study heterogeneity, predictive intervals, publication bias, small-study effects and whether the results of the observed positive studies were more than expected by chance. On the basis of these calculations, strength of associations was classified using quantitative umbrella review criteria, and credibility of evidence was assessed using the GRADE approach. A total of 23 primary studies (19 conducted in European countries and 4 in the USA) enrolling 8554 participants were included. The evidence on the efficacy of staff training to reduce use of restraint was supported by the most robust evidence (relative risk RR = 0.74, 95% CI 0.62-0.87; suggestive association, GRADE: moderate), followed by evidence on the efficacy of shared decision-making interventions to reduce involuntary admissions of adults with severe mental illness (RR = 0.75, 95% CI 0.60-0.92; weak association, GRADE: moderate) and by the evidence on integrated care interventions (RR = 0.66, 95% CI 0.46-0.95; weak association, GRADE: low). By contrast, community treatment orders and adherence therapy had no effect on involuntary admission rates. Different levels of evidence indicate the benefit of staff training, shared decision-making interventions and integrated care interventions to reduce coercive treatment in mental health services. These different levels of evidence should be considered in the development of policy, clinical and implementation initiatives to reduce coercive practices in mental healthcare, and should lead to further studies in both high- and low-income countries to improve the strength and credibility of the evidence base.

Safety Unseen: Leveraging Design to Improve Inpatient Mental Health-Care Practices.

When a patient attacks a nurse, there is more than physical trauma that occurs. The consequences of the violence can manifest in anger, fear, anxiety, shame, blame, and post-traumatic stress disorder symptoms that can have negative effects on patient care and job satisfaction. In the past, design strategies in inpatient psychiatric centers upheld safety by erecting barriers between patients and staff, or over-using restraints and seclusion, strategies that communicated fear and distrust. Now, understanding of how people respond in a state of crisis is changing how care can be delivered in inpatient settings. Once seen as counterintuitive, eliminating physical barriers and opening connections between staff and patients are elevating safety by reducing the psychological walls that keep patients from feeling trusted and respected. By recognizing the human need to have choice and a sense of control in a world that feels out of proportion, health-care organizations can leverage design strategies that address aspects such as spatial density and zones of personal comfort, improving safety by elevating choice and dignity in a therapeutic healing environment.

Interface entre Estresse Precoce e Depressão em adultos: uma análise reflexiva

O presente trabalho tem como analisar reflexivamente com base na literatura a associação do estresse precoce e o desenvolvimento de depressão. O método caracteriza-se como um estudo descritivo, do tipo análise reflexiva, com discussão da literatura a partir de três categorias: estresse precoce, depressão e influências do estresse precoce na depressão em adultos. Como resultados, as experiências de estresse precoce influenciam os sistemas neurobiológicos, dentro dos limites genéticos, levando a manifestações comportamentais de depressão. São essas experiências adversas na infância que contribuem significativamente na fisiopatologia da depressão. O papel do estresse no desequilíbrio do processo saúde-doença está relacionado a causas multifatoriais. No entanto, conhecer o que acontece entre o estresse, na sua forma mais primária, estresse precoce e o desenvolvimento do adoecimento psíquico, em especial a depressão, é essencial para o direcionamento das práticas de assistência em saúde mental tanto no âmbito intervencionista como no âmbito preventivo. Faz-se necessário novos estudos na área, sobretudo os relacionados aos aspectos neurobiológicos.

Assessment of Spiritual Health and Well-Being of Psychiaric Nurses in a Mental Health Hospital

The practice of mental health care performed by nurses in mental hospitals requires nurses to also provide spiritual care. Nurses who have a healthy spiritual state can certainly provide good spiritual care to their patient. Unfortunately, nurses admit that in practice, this spiritual element is often overlooked and not considered important in practice. This study aims to examine the health and spiritual well-being of mental health nurses working in mental health care facilities (hospital based). This research was a pilot study using Mix Method (MM), the design of this study was a sequential research design (Qual-Quant) between quantitative and qualitative study. Data collection was carried out using a self-administered survey and using the SHALOM (Spiritual Health and life orientation measure) instrument from Fisher which had a total of 22 questions. Quantitative data analysis was performed using descriptive statistics, while qualitatively, the data were analyzed using the thematic analysis method. A total of 22 mental health nurses participated in this research project. This number represents the nurses who work in all wards in mental hospitals. Researchers used the cluster sampling method to select participants who were given questionnaires and the snowball sampling method to find suitable informants to be interviewed. This research shows nurses expressing worship of the Creator (Mean = 4.54, SD = 0.59) as the most important thing in the ideal standard of health and spiritual well-being. Likewise, with daily life and practice (Mean = 3.81, SD = 1.68). Nurses assess their health and spiritual well-being were more determined by the transcendental domain, especially with religious rituals. This study concluded that nurses have a well-distributed state of health and spiritual well-being ranging from the personal domain to transcendence, with dominance in the transcendence domain.

A Values-Based Analysis of Recovery-Oriented Practice in Mental Health Care and Medical Assistance in Dying

The Criminal Code of Canada has been amended to allow medical assistance in dying (MAiD) under prescribed criteria. There has been considerable debate regarding whether people with mental illness as the sole underlying medical condition should be eligible. It is argued that access to MAiD is not compatible with recovery-oriented care. Based on a comprehensive analysis exploring the ethical principles guiding decision making around MAiD, this paper offers a discussion of the compatibility between MAiD and recovery-oriented care and demonstrates significant overlap of these principles. The discussion around MAiD as an option in recovery-oriented care is legitimate and needs to continue.

Creation of consensus recommendations for collaborative practice in the Malaysian psychiatric system: a modified Delphi study

BackgroundThere is strong evidence that collaborative practice in mental healthcare improves outcomes for patients. The concept of collaborative practice can include collaboration between healthcare workers of different professional backgrounds and collaboration with patients, families and communities. Most models of collaborative practice were developed in Western and high-income countries and are not easily translatable to settings which are culturally diverse and lower in resources. This project aimed to develop a set of recommendations to improve collaborative practice in Malaysia.MethodsIn the first phase, qualitative research was conducted to better understand collaboration in a psychiatric hospital (previously published). In the second phase a local hospital level committee from the same hospital was created to act on the qualitative research and create a set of recommendations to improve collaborative practice at the hospital for the hospital. Some of these recommendations were implemented, where feasible and the outcomes discussed. These recommendations were then sent to a nationwide Delphi panel. These committees consisted of healthcare staff of various professions, patients and carers.ResultsThe Delphi panel reached consensus after three rounds. The recommendations include ways to improve collaborative problem solving and decision making in the hospital, ways to improve the autonomy and relatedness of patients, carers and staff and ways to improve the levels of resources (e.g. skills training in staff, allowing people with lived experience of mental disorder to contribute).ConclusionsThis study showed that the Delphi method is a feasible method of developing recommendations and guidelines in Malaysia and allowed a wider range of stakeholders to contribute than traditional methods of developing guidelines and recommendations.Trial registration Registered in the National Medical Research Register, Malaysia, NMRR-13-308-14792

A heuristic model for collaborative practice\u2014part 2: development of the collaborative, dialogue-based clinical practice model for community mental health and substance abuse care

BackgroundVarious models for collaborative practice in mental health care incorporating the perspectives of service-user participation and collaboration in the care have been developed. However, the emphasis in these practice models has not been on identifying specific features of “how” collaboration and service-user participation can occur and be nurtured. This suggests a need for a collaborative practice model that specifies essential strategies operationalizing the tenets of service-user participation and collaboration applicable in mental health and substance abuse (MHSA) care.MethodsA double helix approach of coalescing theoretical ideas and empirical findings to develop a practice model that is applicable in MHSA practice. A theoretical analysis is carried out to identify the critical, foundational elements for collaborative practice in MHSA practice, and has identified the philosophical-theoretical orientations of Habermas’ theory of communicative action, Bakhtin’s dialogicality, and the philosophy of personhood as the foundational features of collaboration. This base is juxtaposed with the results of a qualitative meta-analysis of 18 empirical articles on collaboration in MHSA to advance a collaborative practice model specifically in the domain of service user/professional collaboration.Results“The collaborative, dialogue-based clinical practice model” (CDCP Model) for community mental health care is proposed, within the structure of four main components. The first specifies the framework for practice that includes person-centered care, recovery-orientation, and a pluralistic orientation and the second identifies the domains of collaboration as service user/professional collaboration, inter-professional collaboration, and service sector collaboration. The third identifies self-understanding, mutual understanding, and shared decision-making as the essential principles of collaboration. The fourth specifies interactive-dialogic processes, negotiated-participatory engagement processes, and negotiated-supportive processes as the essential strategies of collaboration applicable in service user/professional collaboration which were extracted in the empirical work. An illustration of the CDCP Model in a clinical case is given.ConclusionsThe CDCP Model presented fills the gap that exists in the field of community MHSA practice regarding how to operationalize systematically the tenets of person-centeredness, recovery-oriented, and pluralism-oriented practice in terms of user/professional collaboration.

The conditions of possibilities for recovery: A critical discourse analysis in a Danish psychiatric context.

This paper explores the conditions for the possibilities of recovery in a Danish mental healthcare practice, expressed from the perspective of nurses. The results and discussion of the study help to make visible and explore the muddle of conceptualisations of recovery in mental healthcare practice. Few studies examine the possibilities of recovery for inpatients and outpatients in mental health centres from a nursing perspective. A qualitative design using a critical social constructionist frame of understanding, in which the real world is considered as a series of social constructions. A Fairclough-inspired critical discourse analysis was chosen as the analytical strategy. The analysis is comprised of ten interviews in mental health care and notes, written by nurses, in medical records of ten patients with a mental illness admitted to a mental healthcare centre in 2016-2017. The Consolidated Criteria for Reporting Qualitative Research checklist was used as a guideline to secure accurate and complete reporting of the study (See Appendix S1). From the findings of the textual analysis and the analysis of the discourse practice, it seems clear that the social relations and structures relating to recovery in Danish psychiatry are steered and controlled by discourses that reflect, in general terms, the essence of the core of neoliberal ideology. Recovery is generally articulated from an overall discourse of neoliberalism with its embedded discourses of paternalism, biomedicine, self-care and holism. All these discourses coexist in nursing practice, but the paternalistic discourse becomes the framework for the conditions for the possibility of how recovery is expressed in practice. Nurses need to be supported to seek clarity in the understanding and operationalisation of a recovery-oriented approach, if the agenda is to be truly adopted and strengthened.

The Design of Ecological Momentary Assessment Technologies

AbstractEcological Momentary Assessment (EMA) methods and technologies, designed to support the self-report of experience in the moment of daily life, have long been considered poised to revolutionize human-centred research, the practice of design and mental healthcare. The history of EMA is inextricably linked to technology, and mobile devices embody many of the characteristics required to support these methods. However, significant barriers to the design and adoption of these systems remain, including challenges of user engagement, reporting burden, data validity and honest disclosure. While prior research has examined the feasibility of a variety of EMA systems, few reviews have attended to their design. Through inter-disciplinary narrative literature review (n = 342), this paper presents a characterization of the EMA technology design space, drawing upon a diverse set of literatures, contexts, applications and demographic groups. This paper describes the options and strategies available to the EMA systems designer, with an eye towards supporting the design and deployment of EMA technologies for research and clinical practice.

The importance of faith-based mental healthcare in African urbanized sites.

This review highlights what current research says about how local beliefs and norms can facilitate expansion of mental healthcare to meet the large unmet need for services in Africa. In contemporary Africa, religious beliefs exert important influences on mental health as well as the way people with mental illnesses are viewed and cared for. Mental healthcare practices based on traditional and other religious beliefs, and offered by complementary and alternative health providers (CAPs), reflect the people's culture and are often preferentially sought by a majority of the population. Despite important differences in the worldviews of CAPs and biomedical mental healthcare practitioners in regard to causal explanations, there are nevertheless overlaps in the approaches of both sectors to the management of mental health conditions. These overlaps may provide a platform for collaboration and facilitate the scaling-up of evidence-based mental health services to underserved African populations, especially those residing in ever-expanding urban centres. Faith-based mental healthcare is an important but informal component of the mental health system in much of Africa. Collaboration between its practitioners and biomedical practice may help to bridge the large treatment gap for mental health conditions on the continent.

Working on and with Relationships: Relational Work and Spatial Understandings of Good Care in Community Mental Healthcare in Trieste

Deinstitutionalization is often described as an organizational shift of moving care from the psychiatric hospital towards the community. This paper analyses deinstitutionalization as a daily care practice by adopting an empirical ethics approach instead. Deinstitutionalization of mental healthcare is seen as an important way of improving the quality of lives of people suffering from severe mental illness. But how is this done in practice and which different goods are strived for by those involved? We examine these questions by giving an ethnographic description of community mental health care in Trieste, a city that underwent a radical process of deinstitutionalization in the 1970s. We show that paying attention to the spatial metaphors used in daily care direct us to different notions of good care in which relationships are central. Addressing the question of how daily care practices of mental healthcare outside the hospital may be constituted and the importance of spatial metaphors used may inform other practices that want to shape community mental health care.

Knowledge and attitudes of Spanish mental health professionals towards advance healthcare directives.

WHAT IS KNOWN ON THE SUBJECT?: AHDs in mental health are fundamental tools in advance care planning processes. It is an important method for involving mental healthcare users in clinical decisions and in providing effective healthcare based around user preferences. AHDs can be applied in situations in which the person may forfeit their legal capacity, according to the Convention on the Rights of Persons with Disabilities. However, the use of AHDs as described above is not yet a reality in Spain. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: The present study surveys the knowledge and attitudes of mental healthcare providers towards AHDs in clinical practice. Although providers had a moderate-low level of knowledge about AHDs, they presented positive attitudes towards them. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: The use of AHDs in mental healthcare practice poses challenges to the Spanish mental healthcare system. Acquiring up-to-date data on the knowledge and attitudes of providers towards AHDs allows organizations to address aspects of their service that require reinforcement. This data could also be used by other countries just starting to use AHDs, as an initial step towards supporting the implementation of a multistage intervention process. More in-depth training for providers would help improve their competence to implement or honour the statements set out in AHDs, the related legal and ethical issues, and liability issues related to their implementation. The Spanish mental healthcare system requires structural changes so that providers can embrace new ways of relating to users and to organize partnerships and a continuity of care centred on user preferences. ABSTRACT: Introduction Advance healthcare directives (AHDs) in mental health offer important information regarding service users' preferences. However, whether AHDs are truly understood by providers is questionable. Aim To survey the knowledge and attitudes of mental health professionals towards AHDs and examine any associations with sociodemographic and occupational variables. Method We cross-sectionally surveyed the knowledge and attitudes of 113 mental health professionals by using two validated questionnaires. Results Participants showed very positive attitudes and high levels of knowledge about the conceptual definition and application of AHDs in clinical practice but their knowledge of the legalities, procedure and registration of AHDs was poor. Working in a community, having a career specializing in mental health or having personally signed an AHD was associated with enhanced knowledge about them. Moreover, female sex or employment as an auxiliary nursing-care technician was associated with stronger positive attitudes. Discussion Legal and structural changes will be needed to implement AHDs in Spain and to promote competence among healthcare providers in order to include AHDs in everyday practice. Implications for practice The Spanish mental healthcare system requires legal and structural changes and must improve healthcare providers' competence in AHDs before they are implemented.

The intersection between being a nurse and being a therapist in Mental Health.

to discuss the intersection between being a nurse/being a therapist in the mental health field. exploratory, qualitative study based on a self-report interview conducted with ten nurses from a psychiatric hospital in Rio de Janeiro between June and July 2017. Data were analyzed in the light of Travelbee's theory. Nurses consider themselves therapists because of actions performed in mental health care practice, despite the theoretical fragmentation of interpersonal relationships identified in the distance from the promotion of self-knowledge, which is an essential element in the psychotherapeutic process. the strong relationship between being and doing in nursing stands out and favors the development of satisfactory therapeutic relationships with the hospitalized person.

Postpartum maternal distress: a multidimensional illness requiring a multilevel, multidiscipline response.

Australia's federal, state, territory and local governments all have responsibilities, often overlapping, for policy and delivery of primary mental health care to postpartum women. Identification and treatment of postpartum distress is carried out by a broad range of professionals from diverse disciplines. Although there is evidence to show that anxiety and stress are important aspects of postpartum distress, substantially greater emphasis has been given to identification and treatment of depression. In addition, relatively little attention has been given to incorporating positive and negative social experiences in healthcare policy and practice. This study aimed to extend the postpartum literature by: (1) comparing the levels of depression, anxiety and stress (i.e. distress indicators) in a non-clinical sample of postpartum mothers to those in the general non-clinical population; (2) comparing the prevalence of anxiety and stress to that of depression in postpartum mothers; and (3) examining the consequences of negative social exchange, alongside perceived social support, on postpartum distress indicators. A self-report survey was completed by 242 postpartum women assessing levels of perceived social support, frequency of negative social exchange and distress indicators. Postpartum mothers were found to have significantly higher depression, anxiety and stress than the general population, and had anxiety and stress levels that were similar in severity to depression. In addition, both negative social exchanges and perceived social support were found to be important for postpartum depression, anxiety and stress. These findings suggest that Australia's primary postpartum mental health care policy and practice guidelines, delivered through a broad range of professionals, may benefit from giving anxiety and stress equal weight to depression and by embracing the important effects, for good and for ill, of positive and negative social interactions.

The Role of Age, Education, and Digital Health Literacy in the Usability of Internet-Based Cognitive Behavioral Therapy for Chronic Pain: Mixed Methods Study.

BackgroundInternet-based cognitive behavior therapy (iCBT) can be effective in mental and somatic health care. Research on the feasibility of internet interventions in clinical practice is, however, still scarce. Studies with a focus on the patient regarding usability of interventions and digital health literacy skills are especially lacking.ObjectiveThe goal of this study was to assess the usability of an iCBT for chronic pain, Master Your Pain, and the relationship between its usability outcomes and the factors age, educational level, and digital health literacy skills. The aims were to determine what changes were needed in the program for sufficient usability and which individual characteristics were related to the usability of the program.MethodsPatients were recruited from two mental health care practices. A mixed methods approach was used in this study. A qualitative observational study comprising performance tasks in the iCBT program was used to test usability. A quantitative questionnaire was used to measure possible related constructs. Usability was operationalized as the number of tasks that could be completed and the type and number of problems that occurred while doing so. Performance tasks were set up to measure 6 digital skills: (1) operating the computer and internet browser, (2) navigation and orientation, (3) using search strategies, (4) evaluating relevance of content, (5) adding personal content, and (6) protecting and respecting privacy. Participants were asked to think aloud while performing the tasks, and screen activities and webcam recordings were captured. The qualitative observational data was coded using inductive analysis by two independent researchers. Correlational analyses were performed to test how usability relates to sociodemographics and digital health literacy.ResultsA total of 32 patients participated, with a mean age of 49.9 years and 84% (27/32) being female. All performance tasks except one (fill in a diary registration) could be completed independently by more than 50% of the participants. On operational, navigation, and search levels, participants struggled most with logging in, logging out, and finding specific parts of the intervention. Half of the sample experienced problems evaluating the relevance and adding content to the program to some extent. Usability correlated moderately negatively with age and moderately positively with digital health literacy skills but not with educational level.ConclusionsThe results provide insight into what is essential for proper usability regarding the design of an iCBT program considering variations in age, educational level, and digital health literacy. Furthermore, the results provide insight into what type of support is needed by patients to properly use the intervention. Tailoring support among the needs of certain age groups or skill levels could be beneficial and could range from no extra support (only online feedback, as intended) to practical support (an additional usability introduction session) to blended care (combined face-to-face sessions throughout the therapy).

A study to explore decision-making in psychological counsellors and psychotherapists whose clients report illicit or harmful fantasies during therapy

ABSTRACT Within the context of psychological counsellors and therapeutic encounters of psychotherapists, clients may reveal illicit fantasies where it is unclear whether he or she is acting out his or her illicit fantasies. Using web-based survey methods to collect qualitative data, I explored therapists' decision-making when clients disclose illicit fantasies in such circumstances. Data analysed thematically revealed that most therapists were confident in asking direct questions about illicit fantasies. However, therapists working in private practice appeared to be less likely to estimate risk or “dangerousness” objectively than therapists working in the NHS were. Implications for mental health care practice are considered.

The study of the subjectivity of mental health professionals: an experience in Brasília

This paper discusses the relevance of Gonzalez Rey's Theory of Subjectivity and Qualitative Epistemology for advancing a cultural-historical psychology that articulates research and professional practices in mental health care. This paper presents the outcomes of an empirical research that was carried out with the professional staff of a Brazilian community mental health service based on the constructive-interpretative methodology. The objective of the research was to develop a theoretical model that supports educational practices aimed at the subjective development of the professional team of a community mental health service in Brasilia (Brazil). The outcomes emphasize the relevance of dialogue as a key epistemological and methodological device for individuals to emerge as active agents. From this perspective, research is inseparable from professional practice. In the process, alternative paths are created, which are oriented to subjective development of individuals, social groups and institutions in its broadest sense.