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‘A place to be (me)’: a qualitative study on an alternative approach to treatment for persons with dual diagnosis
Abstract
Objectives: This study aims at gaining insight into an alternative approach to treatment for persons with dual diagnosis by unraveling the daily practice of Villa Voortman, a community-based meeting place in Ghent (Belgium) offering support to this group.
Methods: Twelve in-depth interviews were conducted with several actors: visitors, staff members, volunteers, and persons involved from outside the meeting place.
Results: First, Villa Voortman was experienced as ‘a place to be’, providing visitors a possibility to feel safe and accepted, and belong to a peer group. Voluntary participation to activities is crucial to install such feeling. In time, the meeting place also becomes ‘the place to be’, as visitors start to feel at home. Secondly, it functions as ‘a place to be me’, helping participants to (re-)build their identity and become visible citizens.
Conclusions: The findings are highly consistent with recovery literature and Lacanian ideas on the treatment of psychosis. Some ‘contours’ that shape the daily practice of Villa Voortman could be identified: particularizing to personal needs, having a focus on personal, social, and structural aspects of recovery and the coexistence of different discourses.
... Experiencing stigma was a prominent finding across the literature for people living with SMI and was found to be a macro-level barrier to recovery that was closely tied to cultural and historical perceptions of SMI (Bone, 2018;Buck et al., 2013;De Ruysscher et al., 2019;Lawson et al., 2014;Lloyd et al., 2007;Mizock et al., 2014;Parr, 2006). ...
... Basically, if you're diagnosed with a mental disease, then you're an outcast, a failure in the family, like married wrong, and so on." (Mizock et al., 2014(Mizock et al., , p. 1271 Poor experiences within clinical mental health services also contribute to stigma, with individuals becoming labelled as a "patient" (Baker et al., 2016;De Ruysscher et al., 2019;Lawson et al., 2014;Mizock et al., 2014;Parr, 2006;Yanos et al., 2010). Such stigmatised perceptions become internalised, overwhelming identity and leading to the formation of a negative illness identity (Lloyd et al., 2007;Yanos et al., 2010). ...
... • These factors were key in the identity change from SMI to peer worker Male (5) Female (13) 18 organisational level by promoting artistic practise, which removes expectations to engage in recovery or therapeutic activities. Conversely, a shared experience of SMI is also a requirement for the groups to feel safe (Baker et al., 2016;De Ruysscher et al., 2019;Parr, 2006). Parr (2006) argues that ambiguity about a groups' purpose can affect engagement with recovery. ...
Identity has been empirically established as a recovery process from serious mental illness (SMI) yet is often overlooked within intervention evaluations. Community arts presents one such intervention with emerging evidence illustrating the potential for recovery to occur within this context. However, research indicates numerous mechanisms may be involved in the identity recovery process, making it difficult to determine what works, for whom and in what context. The current review aimed to generate new theories to explain how, why and in what context community arts enable the identity change recovery process for individuals with SMI. A realist review was conducted between January and September 2021, with 22 articles and reports reviewed and synthesised to develop a theory. A safe and empowering intervention context was found to be vital to activate three key mechanism pathways: (a) feeling in control of SMI through coping; (b) achieving acceptance through connectedness and (c) overcoming personal challenges. The outcome was the development of positive self-awareness, which enables individuals to redefine identity beyond SMI through both social and personal identities. Novel insights are presented through theory development, utilising the Social Identity Approach to Health and Transformative Learning Theory to conceptualise the findings through a multi-theoretical lens.
... Previous research into the daily practice of this meeting place has been focusing on the functions it fulfills in the lives and recovery processes of its service users [32]. The results showed how on the one hand, the meeting place is experienced as a place to be, i.e. a safe place where visitors feel welcome and accepted, and gradually even start to feel 'at home' . ...
... In other words, because of this radical and welcoming openness, visitors are encouraged and invited to rebuild a sense of sense away from spoiled and problem-focused identities (e.g. mentally ill, addicted, homeless) and to establish a unique language to engage in dialogue with others [32]. On the other hand, through activities such as the 'Open/ Closed Gate' events and theatre productions, the meeting place appeals to and evokes the hospitality of the neighborhood and society, thus actively claiming visible citizenship of its service users [32]. ...
... mentally ill, addicted, homeless) and to establish a unique language to engage in dialogue with others [32]. On the other hand, through activities such as the 'Open/ Closed Gate' events and theatre productions, the meeting place appeals to and evokes the hospitality of the neighborhood and society, thus actively claiming visible citizenship of its service users [32]. This shows how inclusive citizenship, that is often put forward as a pivotal dimension of mental health recovery [40,41], is not just a static recovery-oriented objective. ...
Background
The recovery processes of persons with complex mental health needs take a slow and unpredictable course. Despite the fact that a number of essential building blocks of recovery in this population have been identified (e.g. social relationships, treatment, personal beliefs), the actual process of recovery in persons with complex mental health needs largely remains a black box. The aim of this study was to gain insight into how the recovery processes of persons with complex mental health needs take place, by applying a relational geographical approach and scrutinizing the place-making dynamics of one low-threshold meeting place in Belgium engaging with this group.
Methods
Data collection took place during the height of the COVID-19 pandemic by means of 11 in-depth interviews with different involved actors (service users, staff members, volunteers) and analyzed thematically.
Results
Results showed how the daily practice of the meeting place is continuously reproduced through place-making rituals that create an inclusive space of hospitality, are fueled by creative processes and form an indispensable counterweight for service users’ mental health needs.
Conclusions
To further open up the ‘black box’ of recovery in persons with complex mental health needs, it is vital to focus our analytic gaze onto recovery as a dynamic and relational practice.
... First of all, the results resonate well with existing evidence that support should be organized from a person-centered and holistic perspective (cf. 'a tailor-made approach'), in which persons with complex mental health needs themselves hold the compass that directs their support trajectories [37,38]. This, amongst other things, requires a specific attitude from mental health care professionals who should take on the role of travel companions that engage in an on-going dialogue with service users about their needs, aspirations and meaning of recovery. ...
... Remarkably, our study shows striking similarities with the results of another study that focused on the daily practice of an alternative community-based meeting place. Whilst this setting can be situated at the other end of the mental health care continuum to an inpatient ward, it engages with a similar group of persons with complex mental health needs [37]. Like the inpatient ward, the meeting place is experienced as a safe haven where visitors (as clients are called) feel welcome and accepted. ...
Background:
Today, international mental health care increasingly focuses on creating recovery-oriented systems of support. This study aims to unravel the daily practice of an inpatient psychiatric ward that engages with persons with complex mental health needs.
Methods:
17 in-depth interviews were conducted with patients and staff of the ward. Data was analyzed by means of thematic analysis.
Results:
Three important functions of the ward were identified in the participants' experiences. First, it functions as an asylum, a safe environment where patients can 'simply be'. Second, the ward is experienced as a particularizing space, as support is organized in an individualized way and patients are encouraged to reconnect with their own identity. Third, the ward functions as a transitional space towards a valuable community life, in which finding adequate housing is of central importance.
Conclusions:
The results show that inpatient forms of support tally with personal and social dimensions of recovery and fulfill important roles in recovery-oriented systems of support.
... This study took place in Flanders (Belgium), where the recovery concept has gained dominance in mental health care during the last 10 years. Pete and Clara met for the first time at Villa Voortman, a community-based meeting place for persons with dual diagnosis in Ghent, in January 2013 (De Ruysscher, Vanheule, and Vandevelde 2017). Villa Voortman offers a welcoming shelter for persons with co-occurring psychosis and addiction problems who have lost connection to regular treatment. ...
... Consequently, they stand in the way of a personalized treatment approach that is tailored to the lifeworld, personality, needs and wishes of each person. In his recovery story, Pete also expressed this need for personalization and differentiation by saying that the 'psycho-social reintegration of the mental hospital population into general society [is desirable] for patients who want that' (original emphasis), thus pointing out the need for a particularizing approach that starts from the personal meaning of recovery for each person with mental health problems (De Ruysscher, Vanheule, and Vandevelde 2017). ...
While the recovery concept strongly resonates in clinical mental health care today, it first arose in service user-led contexts. A major risk of this professionalization shift is that recovery primarily becomes defined by treatment providers. This study aims to keep the debate on recovery alive through a collaborative exploration of Pete’s recovery process by means of a bricolage approach. This resulted in an idiographic portrait of Pete’s experiences of recovery and treatment, clustered around four themes: life rebuilding, identity, continuity of care and the role of drugs. His experiences illustrate a number of contradictions in the operationalization of the recovery ethos in today’s mental health care; whilst recovery appears as a hopeful vision of empowerment, it also risks being reduced to a tokenistic model that fails to address the social realities of people in recovery and in which the assumption that mental illness is chronic is still latently present.
... Dual diagnosis is a multifaceted issue that poses significant challenges in patient care (De Ruysscher et al., 2019). The complexity of this issue necessitates careful consideration and management strategies to ensure consumers are given appropriate care and support. ...
Accessible Summary
What is known on the subject?
Dual diagnosis is one of the leading causes of disability globally.
There is limited evidence on mental health nurses' attitudes towards consumers with dual diagnosis.
What does the paper add to existing knowledge?
Mental health nurses have positive attitudes towards consumers with dual diagnosis.
A positive attitude at work is influenced by various factors, including feeling that one's role is appropriate and legitimate. This also includes receiving support in that role, being motivated to work, having confidence in completing tasks and feeling satisfied with one's job.
Abstract
Background
Dual diagnosis is a global health concern. This descriptive research assessed mental health nurses' attitudes towards consumers with dual diagnosis in Australian mental health settings. The research question was: What is the attitude of mental health nurses towards consumers with co‐existing mental health and drug and alcohol problems?
Materials and Methods
This cross‐sectional survey included 103 mental health nurses who work with consumers with dual diagnosis. Participants were recruited from various mental health settings through convenience sampling. The Comorbidity Problems Perceptions Questionnaire was used to assess attitudes. Descriptive data and multiple regression analyses were conducted. We utilized the consensus‐based checklist for reporting results of this study.
Results
Mental health nurses positively perceived consumers with dual diagnosis. Factors associated with a positive attitude were a higher level of work experience, feeling that one's role is adequate, perceiving one's role as legitimate, receiving increased support in one's position, having high work motivation, possessing high task‐specific self‐esteem and experiencing higher levels of work satisfaction. Work experience predicted role adequacy. Position predicted role support. The work sector predicted role‐related self‐esteem.
Conclusions
As mental health nurses gain work experience; they develop positive attitudes that boost their self‐esteem and sense of importance towards consumers with dual diagnosis. This constructive mindset also positively affects their work motivation and job satisfaction towards consumers with dual diagnosis. Conducting interventional studies is necessary to examine how clinical experiences, work environments, and job positions can impact attitudes, aiming to improve mental health nursing interventions towards consumers with dual diagnosis.
Implications to Practice
The study found that mental health nurses' positive attitudes towards consumers with dual‐diagnosis are influenced by their experience and knowledge. Moreover, mental health nurses who feel supported, motivated and confident in their roles are more likely to provide high‐quality care to consumers with dual diagnosis. Mental health nurses could provide better care and support if they took a proactive approach and addressed the challenges associated with this consumer population. To be successful in their roles, mental health nurses require access to resources and support from healthcare organizations. As a result, their job satisfaction and attitudes towards consumers with dual diagnosis will be enhanced. In this way, consumers as well as healthcare organizations will benefit.
... In order to enhance consumer well-being and treatment outcomes, mental health nurses incorporate therapeutic communication skills into their practice (McAllister et al., 2019). As a result of a high prevalence of dual diagnosis, consumer welfare and treatment outcomes are adversely affected, and caring for consumers with dual diagnosis is a complex undertaking (De Ruysscher et al., 2019). ...
... Besides their role as cultural mediators, they conducted case management, followed up care trajectories, informed and involved families in the recovery process of their close ones and brought together networks of formal and informal, traditional and ethnocultural forms of care. Increased continuity of care can also facilitate a smooth transition from residential treatment settings to home environments (88). We agreed on the responsibility of substance use treatment to collaborate with social and community networks in order to facilitate the transition process after treatment, as well as on the importance of stigma-decreasing initiatives in religious communities and society to build recovery-supportive environments (28,79,83). ...
Introduction
Structural inequity and stigma impose barriers toward substance use prevention and recovery support for persons with an Islamic migration background in non-Islamic majority countries. Similar issues of differential power often keep them silenced in research. Therefore, we explore the continuum of care for substance use problems regarding persons with an Islamic migration background.
Methods
We draw from a co-creative case study with Arafat, whose lived and professional experiences as a Muslim with a history of problem substance working in the field, were blended with academic literature through the process of ‘plugging in’.
Results
We discuss (1) culturally competent and selective substance use prevention, (2) facilitating access to adequate support services, (3) culturally competent substance use treatment and (4) supporting long-term recovery for persons with an Islamic background from a combined academic, professional and lived experiences perspective.
Discussion
We discuss the need for tailored interventions that are able to overcome structural inequities and address ethnocultural sensitivities, needs and strengths. Intermediary community organizations, cultural competence of treatment and recovery-oriented systems of care may bridge the gaps between what is needed and what is available. However, it is important to be conscious that hands-on solutions at the personal level do not absolve the responsibility of searching for systemic solutions. Furthermore, awareness of the fine line between cultural competence and culturalization, taking into account the danger of essentializing, othering and overlooking other intersectional traits of diversity, is needed.
... Therefore, whereas narratives might help to handle these experiences, actively promoting people to do so might heighten hyper-reflexivity and induce even more estrangement (Skodlar & Henriksen, 2019). An approach focused on cultivating de-reflection (Skodlar & Henriksen, 2019) or mitigating the negative impact of negative symptoms, e.g. by addressing social isolation through fostering positive encounters (De Ruysscher et al. 2019) might as such prove more fruitful. ...
Background
Despite considerable scientific interest in the negative symptoms of psychosis, the subjective dimension of these experiences has barely been studied.
Methods
This paper aims at addressing this shortcoming by means of an Interpretative Phenomenological Analysis of semi-structured interviews with 12 participants with a psychotic disorder.
Results
The analysis yielded three major themes: 1) negative symptoms can be conceptualized as a failure of narratives to account for perplexing experiences participants are confronted with in psychosis; 2) negative symptoms challenge participants to make sense of them with meta-narratives; 3) participants highlight a withdrawn attitude towards life after psychosis.
Conclusions
The standard characterization of negative symptoms as a loss of normal functioning should be revised, as this does not match participants’ subjective experiences. Negative symptoms rather represent hard to verbalize experiences. This difficulty of linguistic expression is not 20 a shortcoming of the person experiencing them, but characteristic of the experiences themselves.
Purpose
The purpose of this paper was to explore interlocking questions relating to how we deal with drugs and medication in crisis residential mental health settings. In particular, it examines issues related to overly medical and simplistic explanations of the relationship between cannabis and psychosis, the positive effects of drugs, the effects of having standard rules for diverse groups of people and the concept of non‐abstinent recovery.
Background
I have used mental health and addiction services for 25 years and I have 6 years' experience as a peer worker, working with many people who use drugs.
Method
This is an opinion piece built around a first‐person narrative.
Keypoints
Drugs can have positive effects and an appreciation and understanding of these effects is essential to understanding persistent drug use. How can we integrate non‐abstinent recovery as a valid and positive choice of recovery pathway?
Accessible Summary
What Is Known on the Subject?
Dual diagnosis is one of the leading causes of disability globally.
Consumers with dual diagnosis have complex needs and are at risk of relapse of their psychiatric symptoms.
Mental health nurses require essential skills, including empathy, to manage consumers with dual diagnosis.
No studies have explored mental health nurses' empathy towards consumers with dual diagnosis.
What Does the Paper Add to Existing Knowledge?
Developing empathy towards consumers with dual diagnosis is complex.
Mental health nurses' unemotional empathy experiences with consumers with dual diagnosis are related to their lack of ability to connect to their consumers' choices and feelings.
Negative attitudes towards consumers with dual diagnosis contributed to nurses' poor empathy experiences.
The unemotional responses of mental health nurses can be caused by factors such as novelty, insufficient information, and neutral evaluation of a consumer's situation.
What Are the Implications for Practice?
The study results benefit researchers, teachers, clinicians, and administrators when designing, developing, and delivering empathy training packages for mental health nurses.
Improving the empathy of mental health nurses towards consumers with dual diagnosis should be a top priority for healthcare leaders and educators.
A core curriculum containing holistic awareness of the biopsychosocial components of dual diagnosis makes it easier for mental health nurses to understand and develop empathy towards consumers with dual diagnosis.
Future studies must address the relationship between attitude, stress, burnout, compassion fatigue and empathy among mental health nurses in relation to consumers with dual diagnosis.
Abstract
Introduction
There is a lack of evidence regarding mental health nurses' empathy towards consumers with dual diagnosis.
Aims
This qualitative study aimed to describe mental health nurses' empathy towards consumers with dual diagnosis in Australian mental health settings.
Method
Through purposeful sampling, interviews were conducted with 17 mental health nurses who have experience in caring for consumers with dual diagnosis. Thematic analysis, as an inductive approach was used, to generate codes and themes from participant data. To report on this qualitative study, we adhered to the ENTREQ guidelines.
Results
Four themes emerged: challenges to develop empathy with consumers, lack of conducive attitude of nurses towards consumers, appraising consumers' emotions accurately and holistically responding to the appraised emotions. The findings indicated that developing empathy towards consumers with dual diagnosis is a complex task.
Discussion
Mental health nurses may struggle to empathize with consumers when encountering confrontational situations. Interventional studies are required to address the relationship between mental health nurses' attitudes, stress, burnout, compassion fatigue and empathy in relation to consumers with dual diagnosis.
Implications for Practice
Understanding why mental health nurses emotional experiences differ about a similar challenging situation experienced by their consumers is vital. Further research on strategies to address empathy issues among mental health nurses could enhance nursing practice and consumer care.
Aim
This study aimed to assess mental health nurses' empathy towards consumers with dual diagnosis in Australian mental health settings. The research question was What is mental health nurses' empathy towards consumers with co‐existing mental health and drug and alcohol problems?
Design and Methods
A cross‐sectional survey was carried out to understand mental health nurses' empathy. The convenience sample included 96 mental health nurses from various mental health settings with experience working with consumers with dual diagnosis. We assessed empathy using the Toronto Empathy Questionnaire. We utilised SPSS™ software to analyse both the descriptive data and multiple‐regression.
Results
The mean empathy score was 47.71 (SD 8.28). The analysis of the association between demographic variables and individual subscales showed an association between the clinical setting and empathy ( p = .031) and sympathetic physiological arousal ( p = .049). The work sector was associated with sympathetic physiological arousal ( p = .045) and conspecific altruism ( p = .008). Emotional contagion ( β = .98, p < .001), emotional comprehension ( β = 1.02, p < .001), sympathetic physiological arousal ( β = 1.01, p < .001) and conspecific altruism ( β = 10.23, p < .001) predicted mental health nurses' empathy.
Conclusions
This study found that most mental health nurses showed empathy towards consumers with dual diagnosis. Mental health nurses who are more empathetic towards their consumers experience emotional contagion. They understand emotions better, show sympathetic physiological responses and exhibit kind behaviour towards consumers.
Implications for the Profession and Patient Care
Further research is required to understand how mental health nurses adapt to consumers' emotional states in different mental health settings. This information can help clinicians make better decisions about care quality for consumers with dual diagnosis.
Impact
This study addressed mental health nurses' empathy towards consumers with dual diagnosis. Mental health nurses showed increased empathy towards consumers with dual diagnosis. The empathy levels vary based on age, clinical setting, work sector and work experience. Mental health nurses' empathy levels were predicted by emotional contagion, emotion comprehension, sympathetic physiological arousal and conspecific altruism. Empathy enhancement among mental health nurses, particularly towards consumers with dual diagnosis, is crucial and should be regarded as a top priority by healthcare leaders and educators.
Reporting Method
Outlined by the Consensus‐Based Checklist for Reporting of Survey Studies (CROSS).
Patient or Public Contribution
No Patient or Public Contribution.
Background:
The issue of dual diagnosis continues to be a global health concern. There is a lack of empirical research on mental health nurses' attitudes toward consumers with dual diagnosis.
Objective:
This study aimed to answer the following research question: How do mental health nurses describe their attitude toward consumers with co-existing mental health and drug and alcohol problems?
Design:
This qualitative study employed purposive sampling to recruit participants. Semi-structured interviews were conducted to explore mental health nurses' attitudes toward consumers with dual diagnosis.
Setting:
This study focused on mental health nurses employed in mental health settings. It placed a particular emphasis on mental health nurses who had experience in caring for consumers with dual diagnosis. Seventeen mental health nurses participated in the interview.
Methods:
Interviews were transcribed verbatim and coded using NVivo™ 12 Plus software. Thematic analysis was used to generate codes and themes inductively.
Results:
Three major themes with a total of eight sub-themes were identified: (1) satisfaction and connection, with three subthemes; (2) combating negativity in others, with two subthemes; and (3) working to improve outcomes, with three subthemes.
Conclusions:
Participants were concerned about their peers' sense of fear and frustration, stigmatized language, and lack of consistency in providing dual diagnosis training for mental health nurses. There is a need to investigate effective strategies to address mental health nurses' stigmatized attitudes, fear, and frustration toward consumers with dual diagnosis.
Wat is een psychose nu echt? Zit je hoofd dan vol met onzin? En hoe praten we met iemand die de werkelijkheid radicaal anders beleeft? Contacten tussen mensen bouwen voort op de verhalen die ze elkaar vertellen. Verhalen over vroeger, en over wie ze zijn of wat ze willen. Bij een psychose verliezen we de grip op die verhalen, en op hoe we ermee onze weg kunnen zoeken. Ook wanneer we praten over psychose is het soms moeilijk een heldere taal te vinden. Toch ervaart 15 procent van de bevolking ooit psychotische ervaringen. Een beter begrip van wat er gebeurt tijdens een psychose kan onze kijk op geestelijke gezondheid radicaal veranderen. Waarom een psychose niet zo gek is gaat op zoek naar begrip, hoop en herstel. Het biedt een nieuw perspectief op wat het betekent een psychose door te maken, en hoe we een taal kunnen vinden om met psychische problemen om te gaan. Bovenal is het een blik op hoe beter spreken en luisteren waanzin een menselijk gezicht kunnen geven.
Background and research focus
Despite a widespread research interest in psychosis, there is little attention for subjective experiences underlying psychotic symptoms (Leader, 2011). However, given the nature of psychotic symptoms, as being a disturbance in the primary self-experience (Sass & Parnas, 2003), bringing subjective experiences into account is invaluable to come to a thorough understanding of these experiences (Parnas & Zahavi, 2002). Therefore, in this dissertation, I start from the stories of patients with respect to their symptoms to map the subjective experiences of psychosis.
Two theoretical frameworks serve as inspiration for this research project: psychoanalysis and phenomenology. Lacanian psychoanalysis (Lacan, 1955-56, 1959; Vanheule, 2011, 2019) states that in psychosis one cannot make use of signifiers (cf. language) in a self-evident way to deal with existential questions. When confronted with such questions, the usual narrative with which one makes sense of his/her experiences does not provide support. At such moments, symptoms arise, with hallucinations implying that strange elements pop up in the narrative and negative symptoms implying that the narrative comes to a halt. Phenomenology, on the other hand, approaches psychotic symptoms as external manifestations of disturbances in the primary sense of self (Sass & Parnas, 2003). Inner experiences lose their self-evident character, giving them an estranging quality. As such they can be experienced as coming from an external force (positive symptoms) or as from a distance (negative symptoms). Both frameworks help to get an insight in subjective experiences and are an addition to one another.
A first psychotic experience I explored were auditory verbal hallucinations (AVH’s). In contrast with common believe, the burden of hallucinations is not so much caused by hearing voices as such, but rather by the content of these voices (Beavan & Read, 2010). Nonetheless, hallucinatory content has seldomly been researched. From a psychoanalytic point of view, content of voices can be linked to the so-called real themes: authority and parenthood, sexuality and relationships, gender identity, and life in the light of death (Lacan, 1959; Vanheule, 2017). Based on these ideas, the content of voices was researched.
During this first study, my attention was drawn to the fact that many participants declared to suffer more from what in clinical terms would be called ‘negative symptoms’ instead of from voices and delusions. Given the subjective burden of these experiences (Ventura et al., 2009), these formed the focus point for the remainder of this research project. Despite extensive research attention for negative symptoms (Azorin et al., 2014), there is only limited attention for the subjective experiences underlying these overt symptoms. In the meantime, first person accounts (e.g. Boevink, 2017; Longden, 2012) indicate that the typical conceptualization of negative symptoms, as being a loss of normal functioning (Kirkpatrick et al., 2006), misses important elements of these experiences. In this research project, I mapped these experiences by means of a literature review, an interview study and a co-creative study regarding recovery from negative symptoms.
In this project, I made use of several qualitative research methods, which were adapted flexibly to do right to the experiences of the participants. This choice had two main reasons. First, qualitative research entails the possibility to map subjective dimensions of psychotic symptoms which are hard to grasp by the means of quantitative methodology. Secondly, this methodology provides participants with the possibility to gain insight in their own experiences by telling about them. As a result, such approach is not only beneficial for scientific knowledge, but also for participants.
Based on the previous, the following research questions were formulated for this project:
1. How can the content of verbal hallucinations be thematically organized, starting from a Lacanian perspective?
2. How can we come to an understanding of the subjective experiences of negative symptoms, inspired by Lacanian and phenomenological theory?
a. What is already known in the literature about subjective experiences of negative symptoms?
b. How do people with psychosis make sense of their experiences of negative symptoms?
c. How can recovery from negative symptoms take shape?
These questions were answered by means of four empirical studies and a methodological reflection on this.
Study overview and research results
Based on the study results and Lacanian theory, I state in this dissertation that psychotic experiences can be understood as broken narratives. From this perspective, hallucinations can be seen as a disturbance of the narrative, whereby strange elements pop up. In Chapter 2, I discuss how the majority of hallucinatory experiences, as reported during interviews with participants with psychosis, can be situated within one of the so-called real themes (Lacan, 1959; Vanheule, 2017): authority and parenthood, sexuality and relationships, gender identity, life in the light of death and what does the other want? The themes of these hallucinations could be situated within the larger life narrative of participants. Some succeeded very well to integrate their hallucinatory experiences in their overall life narrative (metadelusional narrative style), others could not integrate these, but had nonetheless a narrative about these (delusional narrative style), while a last group did not succeed in making sense of these experiences at all (chaotic narrative style).
Chapter 3 summarizes the existing qualitative literature regarding negative symptoms in four clusters: 1) ‘a double experience of disconnection’ discusses experiences of estrangement from the self and from others, and can be linked to a failure of the symbolic register (i.e. language) to organize and make sense of experiences. 2) ‘Being overwhelmed by psychotic experiences’ can be linked to a confrontation with the Real: without a structuring narrative or self-image, experiences can become too intense. 3) ‘An eroded self-image’ discusses how someone’s self-image is affected after a psychotic crisis and how stigmatizing interactions with others hinder to rebuild a positive self-image. On the other hand, people might find support in the identification with a cultivated position of withdrawal. This can be linked to the imaginary register. 4) ‘Failure of social interaction’ at last, can be situated on the intersection of the former three clusters. This theme describes the hardness to interact with others when one experiences/experienced psychosis, causing people to retreat. Apart from these clusters, the ‘detrimental side-effects of psychotropic medication’ were accounted for.
Chapter 4 maps the experiences of negative symptoms based on an interview study. Here, the conceptualization in terms of narratives is taken up again, approaching negative symptoms as the failure of the narrative. This failure expresses itself in: a disconnection from organizing narratives, whereby estrangement comes to the fore; lacking words for one’s experiences; narratives that no longer make sense, causing one to question everyday experiences and be perplexed; losing a consistent sense of self; and being overwhelmed by experiences, when a mediating narrative is missing. While the loss of anchoring narratives is prominent in the experience of negative symptoms, participants actively searched for ways to be able to communicate something about these experiences, by means of a meta-narrative. Many did so by attributing their negative symptoms to external factors, like positive symptoms, their internal battle against their psychosis, depressive feelings after a psychotic episode, the behavior and expectations of others, medication side-effects and their overall living conditions. Apart from that, participants also searched for a framework to grasp something about the experiences themselves, which they found in the use of metaphors, philosophical discourse and delusions. Finally, participants also indicated that they took a different stance towards the world after their psychotic experiences, making they could less easily hook on to “normal” life.
Chapter 5 shortly leaves the path of empirical research and reflects, based on the research trajectory of Chapter 4, on the role of theory in qualitative research. While qualitative methods grow in popularity within psychology, the quantitative paradigm remains dominant. As such, ideas from this quantitative vision largely influence qualitative researchers, leading them to back away from truly interpreting their data and making use of theoretical knowledge in doing so. As a result, qualitative studies remain limited to descriptive categorizations, which fail to reflect the richness of the data. During the data-analysis for Chapter 4, I experienced a similar reservation to make use of my theoretical framework. However, without a theoretical lens, it was very hard to grasp the primary experiences of negative symptoms, given the difficulty to bring these into words. As such, my first attempts at analysis rather focused on secondary negative symptoms. It was only by introducing the concept of the narrative, which could be linked to the Lacanian concept of the signifier chain (Vanheule, 2011), that primary experiences of negative symptoms could be given a central place in the results. Based on these experiences, I argue for the use of a theoretical lens to look at data.
In Chapter 6, narratives are linked to recovery, based on a co-creative trajectory with two experts by experience, Pete and Tanguy. Both of them experienced how narratives no longer provided support during psychotic crisis. Recovery entailed the articulation of narratives which could serve as anchor points. This anchoring could be found as well in metaphors, mantra’s and writing down experiences (Pete) as in a continuous process of articulating one’s experiences by the means of philosophical discourse (Tanguy). In this, claiming ownership over this narrative practice was seen as quintessential for recovery. Both were confronted with others who tried to define their narratives for them and had to search for ways to rebecome the active author of their own stories.
Implications for theory, research, and practice
Several considerations follow from this research project. First, I argue for a re-evaluation of the concept ‘negative symptoms’. Indeed, the typical conceptualization as ‘a loss of normal functioning’ (Kirkpatrick et al., 2006) does not match the complexity of experiences reported by patients. Overall, psychotic symptoms can be considered as manifestations of underlying primary disturbances (Sass & Parnas, 2003). Negative symptoms, more specifically, imply a disturbance in the narration of oneself, which is characterized by feeling oneself no longer implicated in an organizing narrative.
Further, negative symptoms can be linked to the psychoanalytic concept of negative mental automatism (Vanheule, 2018), i.e. a confrontation with a hole in the narrative. However, to come to a full understanding of negative symptom experiences, the effects on the level of the Real (experiences get an overwhelming character, causing one to retreat) and the Imaginary (little lived-through identification with an image as compensation or the breakdown of the self-image) should be taken into account.
With respect to research, a theoretical framework helps to have eye for experiences underlying overt symptoms, which is needed to come to a better understanding of the researched phenomena. Next, theoretical knowledge also supports the meaningful organization of data in qualitative research. Finally, also co-operations with experts by experiences serve a better and more diversified understanding of the experiences under research. Such collaborations do not only benefit scientific insights, but also the people involved in it. Indeed, such collaborations provide the opportunity to articulate supportive narratives with respect to experiences and help to breach stigma and they question implicit assumptions and typical practices from academic researchers.
Creating space for and promoting the articulation of recovery supporting narratives should be a focus point within therapeutic environments. Recovery narratives (e.g. Boevink, 2017) are a common method nowadays which recognizes the benefits of articulating narratives. However the articulation of narratives should be approached in a broader way and not remain limited to stories about mental problems and the recovery trajectory. Other types of narratives can also bring mental consistency. Furthermore, it should be recognized that not everyone finds or wants to find a solution by the means of narratives. Support can for example also be found in living a withdrawn life or by identification with example figures. Moreover, attention should be paid to other factors in the living circumstances of patients which might hinder recovery.
Limitations of this research entail the inherent ineffability of psychotic experiences, making the developed model only an approximation. Furthermore, theoretical discussion remained limited to psychoanalysis and phenomenology. The link with other narrative approaches within psychology should be made in further research. Finally, due to the corona measures, the initial research plans had to be adapted.
Further research is needed to explore how the conceptualization of broken narratives can be used to make sense of other psychotic symptoms. Also what makes that a breach in the narrative leads to the popping up of strange elements for some and a confrontation with emptiness for others should be further investigated.
Overall, it can be concluded that the conceptualization of broken narratives entails a promising way to understand psychotic experiences.
Purpose:
The purpose of this paper is to stimulate nurses and other mental health professionals to reflect on what they understand by a psychiatric diagnosis and how they use this understanding.
Background:
I have twenty years' experience as mental health service user and in this time, I have received numerous diagnoses which have had a variety of impacts on me.
Methods:
The paper began as notes drawn from introspection. I ordered my memories and reflections chronologically to reconstruct this narrative.
Key points:
My case makes the point that psychiatric diagnosis is not an established, universal science like in somatic medicine, but a still evolving complex of contradictions and opinions and should not be treated as authoritative. I aim to challenge what I see as a general overestimation of how much a diagnosis tells you about a person and how you should treat them.
Relevance statement:
This article aims to unsettle what the author sees as a general over-confidence in diagnosis and an over-estimation of what a diagnosis tells you about a person.
In today’s recovery-oriented mental health care practice and research, the perspectives of service users are considered of great importance. However, academic research into mental health care still mainly produces a scientific monologue in which the researcher (without lived experience) has the last word about the subject’s experiences. A fundamental question that remains underexposed in mental health care research is one of relational ethics: how can these monological dynamics be reshaped into a real dialogue between people with and without lived experience? The aim of the current paper is to reflect on the research process that we, an academic researcher and an expert by experience, have conducted in a co-creative way in order to draw a number of key lessons on dialogical research ethics.
Recovery from illicit drug and alcohol use takes place over time and is characterised by a dynamic interaction between internal and external components. An integral part of all recovery journeys is effective community reintegration. After all, recovery is not mainly an issue of personal motivation rather it is about acceptance by family, by friends and by a range of organisations and professionals across the community. Therefore to support pathways to recovery, structural and contextual endeavours are needed to supplement individually-oriented interventions and programmes. One way to do this, is by introducing Inclusive Cities. An Inclusive City promotes participation, inclusion, full and equal citizenship to all her citizens, including those in recovery, based on the idea of community capital. The aim of building recovery capital at a community level through connections and 'linking social capital' to challenge stigmatisation and exclusion, is seen as central to this idea. Inclusive Cities is an initiative to support the creation of Recovery-Oriented Systems of Care at a city level, that starts with but extends beyond substance using populations. This paper describes (and gives examples of) how it is possible to use recovery as a starting point for generating social inclusion, challenging the marginalisation of other excluded populations as well by building community connections.
Objective: While the recovery approach in mental health currently enjoys immense support, it is not without its critics. The most persistent criticisms focus on the individualism underpinning many conceptualisations of recovery. In this paper, we outline the shortcomings of individualistic approaches to recovery, and explore the alternative notion of relational recovery.
Method: We begin this article by reviewing recent research and theory that critiques individualistic approaches to recovery. We then draw together disparate bodies of research that view recovery as an inherently social process.
Results: Our reading of the literature suggests that although many models of recovery recognise relationships or connectedness as a component of the recovery process, an overemphasis on the ‘inner’, subjective experiences of people with a lived experience of mental ill-health largely obscures the interpersonal contexts of recovery. Interpersonal relationships can more accurately be seen as suffusing all aspects of recovery, including experiences such as hope, identity and empowerment.
Discussion: We conclude by arguing that the way forward for mental health systems lies in developing, promoting and implementing approaches that properly acknowledge the irreducibly relational nature of recovery.
The purpose of this integrative review is to examine and synthesize extant literature pertaining to barriers to substance abuse and mental health treatment for persons with co-occurring substance use and mental health disorders (COD). Electronic searches were conducted using ten scholarly databases. Thirty-six articles met inclusion criteria and were examined for this review. Narrative review of these articles resulted in the identification of two primary barriers to treatment access for individuals with COD: personal characteristics barriers and structural barriers. Clinical implications and directions for future research are discussed. In particular, additional studies on marginalized sub-populations are needed, specifically those that examine barriers to treatment access among older, non-White, non-heterosexual populations.
Mental health policy is for staff to transform their practice towards a recovery orientation. Staff understanding of recovery-orientated practice will influence the implementation of this policy. The aim of this study was to conduct a systematic review and narrative synthesis of empirical studies identifying clinician and manager conceptualisations of recovery-orientated practice.
A systematic review of empirical primary research was conducted. Data sources were online databases (n = 8), journal table of contents (n = 5), internet, expert consultation (n = 13), reference lists of included studies and references to included studies. Narrative synthesis was used to integrate the findings.
A total of 10,125 studies were screened, 245 full papers were retrieved, and 22 were included (participants, n = 1163). The following three conceptualisations of recovery-orientated practice were identified: clinical recovery, personal recovery and service-defined recovery. Service-defined recovery is a new conceptualisation which translates recovery into practice according to the goals and financial needs of the organisation.
Organisational priorities influence staff understanding of recovery support. This influence is leading to the emergence of an additional meaning of recovery. The impact of service-led approaches to operationalising recovery-orientated practice has not been evaluated.
The protocol for the review was pre-registered (PROSPERO 2013: CRD42013005942 ).
Although there is now increasing evidence as to the role played by social factors in contributing to the onset of mental health
difficulties, there has been little systematic examination of the role that social factors can play in enabling (or impeding)
recovery. This paper provides a review of the emerging international literature in this area, and is linked to a wider conceptual
review undertaken as part of a major project researching recovery practice in the UK. Research findings are explored in detail
in relation to three areas that had been identified by the wider review as central to recovery: empowerment and control over
one's life; connectedness (including both inter-personal relationships and social inclusion); and rebuilding positive identities
(often within the context of stigma and discrimination). Out of this emerges a clearer picture of the importance of particular
social factors, which starts to define a more broad-based and proactive agenda for mental health social work—with an emphasis
not just on working with individuals, but also on engaging with families and communities. However, there is a need for further
research and development work in order to determine how to intervene most effectively in order to influence specific social
factors.
Purpose
– The co-occurrence of mental health and substance use problems is prevalent, and has been problematic both in terms of its complexity for the person and of the challenges it poses to health care practitioners. Recovery in co-occurring mental health and substance use problems is viewed as with multiple challenges embedded in it. As most of the existing literature on recovery tends to treat recovery in mental health and substance use problems separately, it is critical to assess the nature of our current understanding of what has been described as “complex” or “dual” recovery. The purpose of this paper is to identify and discuss what persons with co-occurring mental health and substance use problems describe as facilitators and barriers in their recovery process as revealed in the literature.
Design/methodology/approach
– The method used for this study was a small-scale review of the literature gleaned from a wider general view. Searches were conducted in CINAHL, Psych info, Medline, Embase, SweMed+, and NORART.
Findings
– Three overarching themes were identified as facilitators of dual recovery: first, meaningful everyday life; second, focus on strengths and future orientation; and third, re-establishing a social life and supportive relationships. Two overarching themes were identified as barriers to dual recovery: first, lack of tailored help and second, complex systems and uncoordinated services.
Originality/value
– The recovery literature mostly focuses on recovery in mental health and substance use problems separately, with less attention being paid in the first-person literature to what helps and what hinders dual recovery.
Recovery has come to mean living a life beyond mental illness, and recovery orientation is policy in many countries. The aims of this study were to investigate what staff say they do to support recovery and to identify what they perceive as barriers and facilitators associated with providing recovery-oriented support. Data collection included ten focus groups with multidisciplinary clinicians (n = 34) and team leaders (n = 31), and individual interviews with clinicians (n = 18), team leaders (n = 6) and senior managers (n = 8). The identified core category was Competing Priorities, with staff identifying conflicting system priorities that influence how recovery-oriented practice is implemented. Three sub-categories were: Health Process Priorities, Business Priorities, and Staff Role Perception. Efforts to transform services towards a recovery orientation require a whole-systems approach.
This paper explores recovery-promoting care as experienced by persons with concomitant severe mental illness and substance misuse. Sixteen in-depth interviews, based on an interview guide concerning their experiences of health, life situation and care, were held with eight participants in an outpatient treatment programme. The analysis aimed to identify themes reflecting the diversity and complexity of the phenomenon recovery-promoting care. Six themes emerged: “entirety”, “participation and reciprocal relations”, “stability”, “symptom control”, “mindfulness”, and “dignity and autonomy”. The participants reported that care conveying experiences of meaningfulness and providing empowerment increased their motivation and their capacity to take an active part in the recovery process. The findings of the study underscore the importance of incorporating the patients’ perspectives on what promotes recovery when offering mental health services.
he implementation of deinstitutional- ization in the 1960s and 1970s, and the increasing ascendance of the com- munity support system concept and the practice of psychiatric rehabilitation in the 1980s, have laid the foundation for a new 1990s vision of service delivery for people who have men- tal illness. Recovery from mental illness is the vision that will guide the mental health system in this decade. This article outlines the fundamental services and assumptions of a recov- ery-oriented mental health system. As the recovery concept becomes better understood, it could have major implications for how future mental health systems are designed. The seeds of the recovery vision were sown in the aftermath of the era of deinstitutionalization. The failures in the imple- mentation of the policy of deinstitutionalization confronted us with the fact that a person with severe mental illness wants and needs more than just symptom relief. People with severe
Over the last few decades, research, policy, and practice in the field of mental health care and a complementary variety of social work and social service delivery have internationally concentrated on recovery as a promising concept. In this paper, a conceptual distinction is made between an individual approach and a social approach to recovery, and underlying assumptions of citizenship and interrelated notions and features of care and support are identified. It is argued that the conditionality of the individual approach to recovery refers to a conceptualization of citizenship as normative, based on the existence of a norm that operates in every domain of our society. We argue that these assumptions place a burden of self-governance on citizens with mental health problems and risk producing people with mental health problems as nonrecyclable citizens. The social approach to recovery embraces a different conceptualization of citizenship as relational and inclusive and embodies the myriad ways in which the belonging of people with mental health problems can be constructed in practice. As such, we hope to enable social services and professionals in the field to balance their role in the provision of care and support to service users with mental health problems.
Qualitative case study methodology provides tools for researchers to study complex phenomena within their contexts. When the approach is applied correctly, it becomes a valuable method for health science research to develop theory, evaluate programs, and develop interventions. The purpose of this paper is to guide the novice researcher in identifying the key elements for designing and implementing qualitative case study research projects. An overview of the types of case study designs is provided along with general recommendations for writing the research questions, developing propositions, determining the "case" under study, binding the case and a discussion of data sources and triangulation. To facilitate application of these principles, clear examples of research questions, study propositions and the different types of case study designs are provided.
Health Service and Population Research Department, Institute of Psychiatry, London, UKIntroductionRecovery has come of age. The recoveryapproach has gained traction in mental health policythroughout the English-speaking world, and – at least rhetorically – within mental healthsystems internationally (Slade et al., 2008). But with age comes responsibility. An idea caninitiate change, but that change must work in practice if it is to be sustained.This special issue on recovery marks a shift from ideology to empirical investigation. Thestudies report dataaddressingimportant questions.Webeginbyidentifying someideologicalstatements made by recovery proponents, and reviewing recent evidence relating to thesebeliefs. We then consider some of the scientific challenges in investigating recovery.“Recovery is a process, not just an outcome”A valid understanding of recovery must be grounded in lived experience. Todd and col-leagues (2012) explore the meaning of recovery for people with bipolar disorder, adding togrowingevidence basedonself-managementinthisgroup(Jones etal.,2011).Theirfindingsmake clear that the key dimensions of personal recovery differ from traditional clinicalpreoccupations.To clarify what personal recovery means, a systematic review was undertaken to collateand synthesise published frameworks and models of recovery (Leamy et al., 2011). A totalof 97 papers from 13 different countries which offered new conceptualisations of recoverywere identified. The types of papers included qualitative studies, narrative literaturereviews, book chapters, consultation documents reporting the use of consensus methods,opinion pieces, editorials, quantitative studies, as well as papers which combined differentmethods.Empirical studies recruited participants from a range of settings including commu-nity mental health teams and facilities, self-help groups, consumer-operated mental healthservices and supported housing facilities. The majority of studies used inclusion criteriathat covered any diagnosis of severe mental illness.A modified narrative synthesis of these papers showed that recovery can be thought of (a)as a journey which varies from one person to another, (b) as inter-linking sets of processes,
Interpretative phenomenological analysis (IPA) is an increasingly popular approach to qualitative inquiry. This handy text covers its theoretical foundations and provides a detailed guide to conducting IPA research.
Extended worked examples from the authors' own studies in health, sexuality, psychological distress and identity illustrate the breadth and depth of IPA research.
Each of the chapters also offers a guide to other good exemplars of IPA research in the designated area. The final section of the book considers how IPA connects with other contemporary qualitative approaches like discourse and narrative analysis and how it addresses issues to do with validity. The book is written in an accessible style and will be extremely useful to students and researchers in psychology and related disciplines in the health and social sciences.
No systematic review and narrative synthesis on personal recovery in mental illness has been undertaken.
To synthesise published descriptions and models of personal recovery into an empirically based conceptual framework.
Systematic review and modified narrative synthesis.
Out of 5208 papers that were identified and 366 that were reviewed, a total of 97 papers were included in this review. The emergent conceptual framework consists of: (a) 13 characteristics of the recovery journey; (b) five recovery processes comprising: connectedness; hope and optimism about the future; identity; meaning in life; and empowerment (giving the acronym CHIME); and (c) recovery stage descriptions which mapped onto the transtheoretical model of change. Studies that focused on recovery for individuals of Black and minority ethnic (BME) origin showed a greater emphasis on spirituality and stigma and also identified two additional themes: culturally specific facilitating factors and collectivist notions of recovery.
The conceptual framework is a theoretically defensible and robust synthesis of people's experiences of recovery in mental illness. This provides an empirical basis for future recovery-oriented research and practice.
After 20 years of development and research, dual diagnosis services for clients with severe mental illness are emerging as an evidence-based practice. Effective dual diagnosis programs combine mental health and substance abuse interventions that are tailored for the complex needs of clients with comorbid disorders. The authors describe the critical components of effective programs, which include a comprehensive, long-term, staged approach to recovery; assertive outreach; motivational interventions; provision of help to clients in acquiring skills and supports to manage both illnesses and to pursue functional goals; and cultural sensitivity and competence. Many state mental health systems are implementing dual diagnosis services, but high-quality services are rare. The authors provide an overview of the numerous barriers to implementation and describe implementation strategies to overcome the barriers. Current approaches to implementing dual diagnosis programs involve organizational and financing changes at the policy level, clarity of program mission with structural changes to support dual diagnosis services, training and supervision for clinicians, and dissemination of accurate information to consumers and families to support understanding, demand, and advocacy.
It is the goal of this study to investigate the first development of the drug-free therapeutic community (TC) in Europe. The paper aims at systemizing information, scattered all over Europe and is the first stage in an ongoing study to record the development of the European TC movement and its influences.
After a study of the grey (hidden) literature, TC pioneers and experts per country were contacted to further elaborate the first findings. Subsequently, a preliminary summary of our findings was published in the Newsletter of the European Federation of Therapeutic Communities (EFTC), inviting additional information and corrections. The authors completed the results for this article with relevant first-hand information, obtained through interviews with European pioneers.
The findings are summarized under three topics: chronology, interconnections and European identity. It was found that from 1968 until 1989, a new therapeutic approach arose all over Europe, modeled after Synanon, Daytop and Phoenix House, New York, through Phoenix House, London and Emiliehoeve in the Netherlands. Therapeutic communities were established in Belgium, Finland, Germany, Greece, Ireland, Italy, Norway, Spain, Sweden and Switzerland as well. These communities were closely-knit and interconnected in their reaction against psychiatric and methadone treatment. The European TCs developed an own identity compared to the American ones.
The European TCs adapted the model of their American predecessors to their own culture, influenced more by milieu-therapy and social learning. Instead of harsh behaviorism, more emphasis was placed on dialogue and understanding. Professionals occupied a more pivotal role and took over the dominant position of ex-addicts. Research, executed by TC professionals gradually entered the TC. A generic network of TC connections, through which the development evolved, was uncovered, and clear regional trends can be observed.
Despite a range of long-standing historical, political, ideological, professional, structural, and practical barriers, there has been, and continues to be, a clear consensus that integration between mental health and addiction services is sorely needed and long overdue. This paper focuses on one dimension of the challenge of integration from among the several - the conceptual - and proposes the construct of recovery as an organizing principle for bridging the divide between the two domains. After reviewing briefly the parallel history of the two traditions and their shared need for transformation to a recovery orientation, the authors offer an integrated model of recovery for persons with co-occurring disorders. They then derive from this model the underlying values, guiding principles, key strategies, and essential ingredients of recovery-oriented systems of care that comprise a common approach across both addictions and mental illness, offering a strengths-based solution to achieving integration where pathology-focused approaches have failed.
The vision of recovery is reshaping the fields of mental health and addiction services. This paper reviews how this broad vision is shaping common goals, principles, values and strategies across the two fields. We further examine how a common vision of recovery can positively impact the treatment of co-occurring disorders and speculate on how this vision can bridge the seeming differences between these two fields and reshape a mutual understanding of the essentials of recovery from severe mental illness and addiction.
In the past, practice in mental health was guided by the belief that individuals with serious mental illnesses do not recover. The course of their illness was either seen pessimistically, as deteriorative, or optimistically, as a maintenance course. Research over the past thirty to forty years has indicted that belief and shown that a vision of recovery can be achieved for many individuals. People with serious mental illnesses have themselves published accounts of their own recovery as well as advocated for the development of recovery promoting services. In North America and other regions, policies have been developed to make recovery the guiding vision of services. Today, particularly in the United States, much effort is going into the transformation of services and systems to achieve recovery outcomes. Despite these trends, the idea of recovery remains controversial and, some say, even illusory. This article clarifies the meaning of the term "recovery", reviews the research and first person accounts providing a rationale for recovery, and sets out implications for developing recovery oriented services.
To review developments in recovery-focussed mental health services internationally.
Two forms of 'recovery' which have been used in the literature are considered, and international examples of recovery-focussed initiatives reviews. A 'litmus test' for a recovery-focussed service is proposed.
'Clinical recovery' has emerged from professional literature, focuses on sustained remission and restoration of functioning, is invariant across individuals, and has been used to establish rates of recovery. 'Personal recovery' has emerged from consumer narratives, focuses on living a satisfying, hopeful and contributing life even with limitations caused by the illness, varies across individuals, and the empirical evidence base relates to stages of change more than overall prevalence rates. Clinical and personal recovery are different. Two innovative, generalisable and empirically investigated examples are given of implementing a focus on personal recovery: the Collaborative Recovery Model in Australia, and Trialogues in German-speaking Europe. The role of medication is an indicator: services in which all service users are prescribed medication, in which the term 'compliance' is used, in which the reasoning bias is present of attributing improvement to medication and deterioration to the person, and in which contact with and discussion about the service user revolves around medication issues, are not personal recovery-focussed services.
The term 'Recovery' has been used in different ways, so conceptual clarity is important. Developing a focus on personal recovery is more than a cosmetic change--it will entail fundamental shifts in the values of mental health services.
Discourses of recovery and resilience have risen to positions of dominance in the mental health field. Models of recovery and resilience enjoy purchase, in both policy and practice, across a range of settings from self-described psychiatric survivors through to mental health charities through to statutory mental health service providers. Despite this ubiquity, there is confusion about what recovery means. In this article we problematize notions of recovery and resilience, and consider what, if anything, should be recovered from these concepts. We focus on three key issues, i) individualization, ii) the persistence of a deficit model, and iii) collective approaches to recovery. Through documentary analysis we consider these issues across third sector organizations, and public and mental health policy. Firstly, definitional debates about recovery reflect wider ideological debates about the nature of mental health. The vagueness of these concepts and implicit assumptions inherent in dominant recovery and resilience discourses render them problematic because they individualize what are social problems. Secondly, these discourses, despite being seen as inherently liberatory are conceptually dependent on a notion of deficit in that talk of “positives” and “strengths” requires the existence of “negatives” and “weaknesses” for these concepts to make sense. We argue that this does little to substantially transform dominant understandings of psychological distress. Thirdly, these issues combine to impact upon the progressive potential of recovery. It comes to be seen as an individualistic experiential narrative accompaniment to medical understandings where the structural causes of distress are obscured. This in turn impacts upon the potential for recovery to be used to explore more collective, political aspects of emotional distress. Drawing on the work of Fraser, we use this critique to characterize “recovery” as a “struggle for recognition,” founded on a model of identity politics which displaces and marginalizes the need for social, political and economic redistribution to address many of the underlying causes of emotional distress. We conclude by stating that it is only when the collective, structural experiences of inequality and injustice are explicitly linked to processes of emotional distress that recovery will be possible.
This paper explores the concept of recovery-oriented social work practice in mental health settings as it is understood and practised by social workers. The authors describe an investigation of the implementation of mental health reforms in Quebec. This study explored the gap between the reforms' philosophical orientations of mental health recovery and its practical realisation. Specifically, we will discuss the ways in which the social work field encompasses approaches that potentially espouse contradictory understandings of recovery. The study highlights the external and internal obstacles and facilitators to recovery-oriented social work practice. This qualitative research project used semi-structured interviews with eleven primary care mental health social workers in two health care agencies to better understand how they situate themselves with respect to the recovery orientation. The findings illustrate the impact of organisational constraints on social workers' attempts to practise from a recovery-oriented perspective. Specifically, they show that (i) managerial orientations espoused by the reforms have paradoxically led to systemic barriers to recovery-oriented practice and (ii) recovery practice by social workers is facilitated in part by their understanding of this philosophy and by leadership on the part of their managers. This paper will allow for a better understanding of social work perspectives and practical frustrations regarding current primary care mental health practice. © The Author 2015. Published by Oxford University Press on behalf of The British Association of Social Workers.
This paper reviews underlying systems of worldwide thought, which underpin the organisation of care, support and (special) education for people with disabilities and behaviour disorders. As the world enters a postmodern age, there is no longer one central and dominant theory by which to guide action. The article reviews a range of theoretical positions, which have supported intervention for people with disabilities and behaviour disorders. It traces historical development of one institution, Ghent University, in the field of orthopedagogy in order to understand how systems of thought have developed and influenced practical action. The paper also provides a critique of existing models of care and (special) education, which sets an agenda for change.
Purpose
– Influenced by evolutions in mental health, a meeting house, “Villa Voortman”, was recently developed. It is based on an integration of therapeutic community (TC) and psychoanalytical Lacanian thinking. The purpose of this paper is to investigate the position of Villa Voortman in the treatment continuum for dually diagnosed clients. Two research questions are addressed: how does Villa Voortman operate ? and how do clients perceive the Villa?
Design/methodology/approach
– The first question was tackled by a personal account of the founders of Villa Voortman. The second question was addressed by a qualitative study using video-material of 19 visitors’ personal accounts.
Findings
– The visitors mentioned three themes: social inclusion, personal development and equality. These aspects are further refined into sub-themes including the provision of “asylum”; the instalment of a warm and welcoming atmosphere; the focus on real human encounter; a permissive, supportive and “waiting” environment; a minimal but “good enough” structure; the necessity of a place where persons can develop themselves; the striving for social inclusion and future perspectives; and the support in becoming inclusive citizens again.
Originality/value
– The value of the paper lies in disclosing the visitors’ lived experience. This is an essential part of shedding light on the “active ingredients” of support, In reference to the title, visitors nor treatment staff have “carte blanche” with regard to how support develops, as this is driven by the dialectal course of everything that occurs during the support process.
As the study of man yields a greater understanding of the social factors that motivate him, channel his activities, sicken or gratify him, it is not surprising that increasing attempts are made to put this information to work in constructing whole social systems designed to realize specific human goals.
The author aims to advance the theoretical understanding of practice wisdom by presenting three propositions in relation to its nature and process. A model of practice wisdom is constructed that seeks to address some issues of critical, accountable and knowledge-based practice, while retaining its flexible, creative and intuitive use of practice knowledge.
Findings: It is argued that a critical, accountable and knowledge-based practice wisdom requires distinctive knowledge production processes, the ability to make reasoning explicit, and credible and valuable knowledge. Models of experienced practice development are needed if social work educators are to effectively facilitate the growth of practice wisdom. Such models will need to set out a framework of how such factors as disposition towards knowledge, professional education, practice experience and practice contexts influence whether practitioners engage in wise practice.
Applications: The article makes a contribution to the debate about the nature of social work practice and how entrants to social work can become effective practitioners. Practitioners, researchers and social work educators can use the presented framework to review their thinking about the nature of social work practice and the place practice wisdom has in contemporary social work.
The mental health recovery movement in the USA has reaffirmed the vital role that human processes play in service delivery
and the ways in which social workers collaborate with clients to bring about change. However, social interaction between social
workers and their clients continues to be an understudied aspect of interventions. Recovery places an emphasis on therapeutic
relationships, demanding that providers collaborate closely with each consumer to discover their unique path to healing. As
a result, researchers must also reorient their focus from the structure of services to the processes that take place during
service delivery. The authors examine how process has been studied within the context of services for people with mental health
problems, how process relates to outcomes and some of the methodological issues related to studying social interaction. Qualitative
methods are recommended to enhance micro-level study of complex human processes within their social context. The authors consider
the implications for evidence-based practice and argue that a broader understanding of evidence, which takes into account
the role of process, is needed in order to ensure that research is relevant to social work practice.
This book examines Jacques Lacan’s contribution to our understanding of psychosis. Presenting a close reading of original texts Stijn Vanheule proposes that Lacan’s work on psychosis can best be framed in terms of four broad periods. In each period a different set of key concepts can be discerned together with a number of crucial texts containing references to psychosis. The precise meaning of these concepts and their implication for the clinic of psychosis are explained in detail. Special attention is paid to Lacan’s discussion of clinical cases and literary works, and to his critical dialogue with related disciplines such as psychology, psychiatry, philosophy, and linguistics. Synthesising ideas from Lacan’s entire oeuvre this book sheds light on the evolution of his theory and provides a valuable tool for students and advanced scholars.
This article examines a central plank of mental health policy (‘recovery’) in societies which have attempted to reverse the long-term warehousing of those with a diagnosis of mental disorder (de-institutionalisation). The emergence of the concept is traced in relation to the shift from an institutional to a more dispersed and community-based form of service organisation. Different usages of the term ‘recovery’, each with distinct implications for practice are considered on the part of three main interest groups (traditional bio-medical psychiatrists; social psychiatrists emphasising social skills training; and dissenting service users). These different usages suggest that ‘recovery’ is a polyvalent concept that creates an uneasy consensus point to define the management philosophies of local services enacting mental health policy. Also mental health work is about more than the group of patients mainly considered in relation to recovery (those with ‘severe and enduring mental health problems’). Practice-near research strategies are now required to investigate the varied practical scenarios these contradictions generate and ethnographic research is therefore indicated. Without multiple ethnographies, we will be left with competing rhetoric about recovery and its meaning or meanings may be rendered worthless.
People who experience mental illness can be viewed as either fundamentally different than, or fundamentally like, everyone else in society. Recovery-oriented mental health systems focus on commonality. In practice, this involves an orientation toward supporting everyday solutions for everyday problems rather than providing specialist treatments for mental illness-related problems. This change is evident in relation to help offered with housing, employment, relationships, and spirituality. Interventions may contribute to the process of striving for a life worth living, but they are a means, not an end. Mental health systems that offer treatments in support of an individual's life goals are very different than those that treat patients in their best interests. The strongest contribution of mental health services to recovery is to support everyday solutions to everyday problems.
Treatment of dual diagnosis [co-occurrence of a substance use disorder (SUD) in patients with mental illness] poses several challenges for mental health professionals. This article seeks to review the recent advances in dual diagnosis treatment with respect to pharmacotherapy and psychosocial approaches.
Atypical antipsychotics are commonly used for comorbid schizophrenia and SUD. Whereas there is no difference between risperidone and olanzapine, clozapine appears to have a distinct advantage in reducing psychotic symptoms as well as substance abuse (including smoking). There is emerging evidence that quetiapine is beneficial in dually diagnosed patients, particularly using alcohol, cocaine and amphetamine. A combination of naltrexone and sertraline was found to be effective in patients with depressive disorder and alcohol dependence. Effectiveness of atomoxetine is yet to be established in patients with comorbid adult attention-deficit/hyperactivity disorder with respect to decrease in substance abuse. Integrated intervention is the choice of treatment for patients with dual diagnosis.
In spite of the high association between substance use and psychiatric disorders, there is a surprising paucity of studies related to treatment and outcome. A few well-designed studies have been recently published and more studies of this nature are required in order to address the challenges posed in the treatment of dual disorders.
Phenomenology is a philosophic attitude and research approach. Its primary position is that the most basic human truths are accessible only through inner subjectivity, and that the person is integral to the environment. This paper discusses the theoretical perspectives related to phenomenology, and includes a discussion of the methods adopted in phenomenological research.
Considerable research documents the health consequences of psychosis and co-occurring substance use disorders. Results of randomized controlled trials assessing the effectiveness of psychosocial interventions for persons with dual diagnoses are equivocal but encouraging. Many studies are hampered by small, heterogeneous samples, high attrition rates, short follow-up periods, and unclear description of treatment components. The treatments available for this group of patients (which can be tailored to individual needs) include motivational interviewing, cognitive-behavioral therapy, contingency management, relapse prevention, case management, and skills training. Regardless of whether services follow integrated or parallel models, they should be well coordinated, take a team approach, be multidisciplinary, have specialist-trained personnel (including 24-hour access), include a range of program types, and provide for long-term follow-up. Interventions for substance reduction may need to be further developed and adapted for people with serious mental illnesses. Further quality trials in this area will contribute to the growing body of data of effective interventions.
In the following commentary on the article by Dr. Lehman and others on dual diagnosis, reprinted on page 1119 from the October 1989 issue of Hospital and Community Psychiatry, Drs, Drake and Wallach discuss the development of clinical understanding of dual diagnosis since the 1980s, Research has shown that among persons with serious mental illness, substance abuse is an underlying factor in violence, incarceration, treatment noncompliance, and HIV risk. Findings support the development of integrated treatment programs that address both types of disorder. Drs, Drake and Wallach describe four perspectives on dual diagnosis-medical, moralistic, psychosocial risk, and phenomenological, They argue that the emphasis on diagnosis and illness may have delayed the development of public policies and programs to address risks for substance abuse inhering in social and environmental settings, such as housing shortages and lack of employment opportunities.
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