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Assertive Community Treatment (ACT) refers to a loosely related set of principles and practices focused on improving the lot of those identified as 'heavy service users', or those people who have historically been difficult to engage in treatment. A burgeoning body of research testifies to the effectiveness of ACT and a bewildering number of acronyms such as PACT, MIT, MCT, TCL and MST have been coined to describe services more or less faithful to ACT principles. This paper describes the key principles of ACT, research on outcomes and ACT programmes, presents a sketch of the Mobile Intensive Treatment Team in Townsville and critiques ACT from an ethical perspective. It proposes that ACT ought to commence from a philosophy of community mental health firmly grounded in respect for people, and ought to be the primary business of community mental health services.

The Queensland Government issued a policy directive to lock all acute adult public mental health inpatient wards in 2013. Despite criticism from professional bodies and advocacy for an alternative, the policy has been retained to this day. A blanket directive to treat all psychiatric inpatients in a locked environment without individualised consideration of safety is inconsistent with least restrictive recovery-oriented care. It is against the principles of the United Nations Convention on the Rights of Persons with Disabilities, to which Australia is a signatory. It is also contrary to the main objects of the Mental Health Act 2016 (Qld). Queensland Health has reported a reduction in ‘absences without permission’ from psychiatric inpatient wards after the introduction of the locked wards policy; however, no in-depth analysis of the consequences of this policy has been conducted. It has been argued that patients returning late or not returning from approved leave is a more common event than patients ‘escaping’ from mental health wards, yet all may be counted as ‘absent without permission’ events. A review of the international literature found little evidence of reduced absconding from locked wards. Disadvantages for inpatients of locked wards include lowered self-esteem and autonomy, and a sense of exclusion, confinement and stigma. Locked wards are also associated with lower satisfaction with services and higher rates of medication refusal. On the contrary, there is significant international evidence that models of care like Safewards and having open door policies can improve the environment on inpatient units and may lead to less need for containment and restrictive practices. We recommend a review of the locked wards policy in light of human rights principles and international evidence.

A common idiomatic phrase in mental health care is 'well known' client, patient, or service user. This phrase is often followed by “to mental health services” or some such, suggesting that a “service” can really know anything. Notwithstanding mental health services, especially public ones are a repository for a lot of information, such as facts about people, their service use, diagnosis, notes and assessments of various kinds; this conglomeration of information is not knowing, any more than a library may be “knowing”. Knowing is a distinctly human activity. This paper will argue that this phrase is arrogant, a signifier of ignorance and ought to be relegated to history or back room banter with phrases like “frequent flyer”, “bed seeker” and other derogatory and objectifying language.

A few years ago I re-discovered a collection of professional souvenirs in a tobacco tin – assorted nursing medals, identity badges and service keys for a psychiatric hospital I had worked at. An inquiry of mental health nurse colleagues found that many had also held onto the keys (some of which are pictured in figure one). According to the authoritative 'Hints for Probationers in Mental Hospitals' reprinted by Gladesville Hospital in 1944 amongst other sage advice was 'Never let a suicidal patient out of your sight … Never allow your key to go out of your own possession' and “Never fail to report immediately a lock out of order”. This enlightened document also exhorted nurses to never treat patients as one mass but to respect their individuality, to maintain optimism and to regard every patient as curable. The charge nurse was un-equivocally and uncontestably responsible for the maintenance of the therapeutic milieu of the ward whether locked or closed…

Personal responsibility is widely considered important in mental health recovery as well as in popular models of alcohol and drug treatment. Neo-liberal socio-political rhetoric around consumerism in health care often assumes that people are informed and responsible for their own choices and behaviour. In the mental health care context and especially in emergency or crisis settings, personal responsibility often raises particular paradoxes. People often present whose behaviour does not conform to the ideals of the responsible consumer; they may seek and/or be granted absolution from irresponsible behaviour. This paradox is explored and clinicians are urged to consider the context-bound nature of personal responsibility and how attributions of personal responsibility may conflict with policy and their own professional responsibilities to intervene to protect others.

The prevailing naive bio-pharmaco-centric approach to human distress has not been found to be helpful to most and often serves to obscure alternative ways of viewing and addressing problems.

The issue of potential conflict of interest and its risk to professional integrity in journal article publication has been strongly debated in medical circles. Most medical journals adhere to international requirements for disclosure of potential conflict of interest. The debate on this issue in nursing, and specifically mental health nursing, has been neither prolific nor strong, despite nursing's potential to influence particular viewpoints about treatment and indeed to prescribe particular treatments; and nursing being a target for pharmaceutical industry marketing. The purpose of this paper is to raise debate about potential conflict of interest in journal article publication and to make recommendations for the management of such potential for this journal.

Examination of the names used to signify a nurse who specializes in working with people with mental health problems indicates the absence of a shared nomenclature and the frequent conflation of the terms 'psychiatric' and 'mental health’. Informed by the work of Derrida (1978) and Saussure (1916–1983), the authors encourage the deconstruction of and problematization of these terms, and this shows that what nurses who work with people with so-called mental illness are called has depended on where they have worked, the vagaries of passing fashion, and public policy. Further, there are irreconcilable philosophical, theoretical, and clinical positions that prevent nurses from practicing simultaneously as 'psychiatric’ and 'mental health’ nurses. Related service user literature indicates that it is disingenuous to camouflage 'psychiatric’ services as 'mental health’ services, and as signifiers, signified, and signs, psychiatric and mental health nursing are sustained by political agendas, which do not necessarily prioritize the needs of the person with the illness. Clearly demarked and less disingenuous signs for both mental health and psychiatric care would not only be a more honest approach, but would also be in keeping with the service user literature that highlights the expectation that there are two signs (and thus two services): psychiatric and mental health services.

There is considerable interest in the various ethical problems associated with undertaking health and social science research. Participants in such research are often considered vulnerable because of their health status, social position or dependence on others for health and welfare services. Researchers and ethics committees pay scrupulous attention to the identification and amelioration of risks to participants. Rarely are the benefits to participants of engaging in research highlighted or drawn to the attention of potential participants. Such potential benefits need to be considered by researchers and reviewers when considering the balance of benefits and harms associated with research projects. This paper particularly considers the psychotherapeutic benefits of participation in research.

This paper considers the ethics, legality and compatibility with mental health recovery and evidence based practice of the enforced wearing of night attire by adults admitted to mental health inpatient facilities. This practice of 'pyjama therapy' continues to persist in some places and is clearly unethical, probably in breach of international human rights law, is antithetical to personal recovery and has no basis as effective in research. Health professionals are urged to consider how in less visible and obvious ways institutional practices, subjugating social dynamics, and demeaning rituals may be played out in encounters with service users.

Background How people integrate the experience of involuntary hospital admission and treatment into their life narrative has not been explored systematically.
Aims To establish a typology of coercion perspectives and styles of integration into life stories.
Method Transcripts of recorded interviews with 15 persons who had previously been involuntarily admitted to hospital were coded and analysed thematically using a modified grounded theory approach.
Results With hindsight, people viewed the experience of involuntary hospital admission as a 'necessary emergency brake', an 'unnecessary overreaction' or a 'practice in need of improvement’. With respect to how they integrated the experience into their life narratives, participants viewed it as 'over and not to be recalled’, a 'life-changing experience’ or a 'motivation for political engagement’.
Conclusions The participants’ diverse and differentiated perspectives on coercive measures and their different styles of integration suggest that people may come to accept coercive measures as necessary when confronted with danger to self or others. However, the implementation of coercion needs to be improved substantially to counteract possible long-term adverse effects.

Ireland has a long history of outward migration but in recent years Ireland has become a destination of choice for migrants from the rest of the world. This has posed a challenge to Irish institutions and Irish society. This paper reports on the findings from a community development project undertaken in partnership between Cairde (a non government resource and advocacy organisation for ethnic minority groups) and Dublin City University. Members of new community groups in Dublin who were affiliated with Cairde took part in focus groups exploring their perceptions regarding mental health, mental ill-health and their experiences of mental health care provision. Participants focused more on their everyday experiences affecting their health and well-being rather than presenting their difficulties from within an illness paradigm. Whilst most participants had experience of accessing health services they had little contact with specialist mental health services. So while the study was designed to focus on conceptions of mental health/ill-health and services, the findings highlight structural inequalities that some migrants face in relation to legal status, accessing educational, occupational opportunities, and social service eligibility; all aspects of their everyday lives that cause them distress and fear.

The relationship between nursing and the pharmaceutical industry is conflicted. The pharmaceutical industry holds commercial interests which are incompatible with the interests of nursing and service users. Nursing and nurses are courted by the industry, most obviously to influence prescribing practices but also to promote a world view that psychiatric drugs are essential, and to sanitise the image of the industry (which has recently been rocked by fresh accusations of unethical practice). Nursing's image, the public trust it enjoys and ultimately good relationships with service users stand to be tarnished unless nursing rethinks its relationship with the industry. Nursing ought to reposition (or restore its position) next to service users rather than next to the pharmaceutical industry.

This paper was peer reviewed and originally accepted for publication in Mental Health Practice. It was even advertised for publication. However, it was withdrawn by a new editor. A satisfactory explanation was not provided and despite a request for the grounds for this editorial decision to be shared with readership this was not provided either.

Although there appears to be a widespread consensus that depression is a ubiquitous human experience, definitions of depression, its prevalence, and how mental health services respond to it have changed significantly over time, particularly during recent decades. Epistemological limitations notwithstanding, it is now estimated that approximately 121 million people experience depression. At the same time, it should be acknowledged that the last two decades have seen the widespread acceptance of depression as a chemical imbalance and a massive corresponding increase in the prescription of antidepressants, most notably of selective serotonin reuptake inhibitors (SSRIs). However, questions have been raised about the effectiveness and iatrogenic side effects of antidepressants; related questions have also been asked about whose interests are served by the marketing and sales of these drugs. Accordingly, this article attempts to problematize the normative orthodoxy concerning depression and creates a "space" in which an alternative can be articulated and enacted. In so doing, the article finds that the search for a world where the automatic response to depression is a pharmacological intervention not only ignores the use of alternative efficacious treatment options but may also inhibit the persons' chance to explore the meaning of their experience and thus prevent people from individual growth and personal development. Interestingly, in worlds analogous to this pharmacologically induced depression-free state, such as utopias like that in Huxley's Brave New World, no "properly conditioned citizen" is depressed or suicidal. Yet, in the same Brave New World, no one is free to suffer, to be different, or crucially, to be independent.

Background. Good quality, ethically sound research is needed in order to better understand, appropriately respond to, and reduce the incidence of suicide. There is, however, a lack of clarity around the nature of ethical problems associated with suicide research and how to resolve them. This is a formidable challenge for ethics committee members in approving and monitoring research.
Aims. To describe the views that members of health research ethics committee hold regarding ethical problems and ethical practice in research involving people who are, or who have, been suicidal.
Methods. Ethics committee members were invited to complete an online survey addressing the risks, benefits, and ethical problems associated with suicide research. Findings were aggregated into themes using an inductive form of content analysis.
Results. Concerns of ethics committees centered on accessing the population, potential harm to participants or the researcher, researcher competency, maintaining confidentiality, providing support to participants, and responding sensitively to the needs of family.
Conclusions. Ethical research involving suicidal people requires both procedures to protect participants, and consideration of ethics as an ongoing negotiated process. The findings of this research provide a snapshot of views held by a number of ethics committee members.

Research is needed to better understand and respond effectively to people who are suicidal. Involving people who are suicidal in research poses some ethical and pragmatic problems. The ethical problems and difficulties in obtaining approval to involve people who are suicidal in research has contributed to the current paucity of research that explores the suicidal experience. To explore some of these problems, a web-based survey of suicide researchers was undertaken. Researchers identified from published reports were contacted by email and invited to participate in a web-based survey. Researchers were asked to describe any problems they encountered, how ethical problems were negotiated or resolved, and any advice received from human research ethics committees. The main problems identified were accessing the population, maintaining confidentiality, the extent of care owed by the researcher to participants, and the facilitation of support to participants. As with clinical practice, ethical research involving people who are suicidal involves a process of sensitive engagement, and careful consideration and remediation of risk.

This paper proposes that some practices and trends in mental health care may be considered as defensive responses to collective anxiety and fear. On a larger scale similar dynamics occur around fear of terrorism. Collectively and individually we are pulled by the defensive forces and dynamics associated with anxiety. This can in part explain the polarization that occurs around issues of definition and response to mental illness. Fear and anxiety push services towards simplistic viewpoints and futile practices. Pluralism, humility and the capacity to view things from the perspective of others may help in channelling anxiety productively.

Psychiatric nursing practice can be likened to an ethical minefield. Nurses are often in the middle of the minefield and are pushed and pulled by forces, which are sometimes beyond their control. This paper signposts some of the more problematic areas of practice so that nurses may be equipped with at least a broad over-view of the ethical terrain.

This paper suggests that one need look no further than New Zealand mental health legislation and the medical hegemony over the compulsory assessment and treatment process to uncover barriers to nursing actualising it's potential

This paper discusses the ethics of bathing someone against their expressed will.

This editorial explores particular forms of epistemic injustice which mental health service users may be exposed to. Mental health service provision throws up some particular problems in relation to developing and sustaining just services. Like the problems which people bring with them to mental health care, justice is multifaceted and multidimensional. Whilst often it may seem that addressing injustice is too big a problem for any but the most heroic of individuals, much injustice is underpinned by testimonial injustice of various kinds which we as health professionals are implicated in perpetuating. Mental health professionals need to reflect on the way we engage with service users, consider their testimony and construct problems. To do so will have far reaching implications for creating just institutions and ultimately just societies.

This paper presents findings from an ethics approved phenomenological study exploring mental health nursing roles and capabilities under the Mental Health Nurse Incentive Program (MHNIP) in two regional centres. Findings will be used to generate critical discussion on profes- sional identity factors such as clinical autonomy, nursing capabilities and effective interventions for young people. Happell, Palmer, and Tennent (2010) identify that the MHNIP offers a greater range of service provi- sion than has been previously available. Indications are that nurses working within the MHNIP are in fact offering a range of interventions beyond what was initially envisioned through providing effective talk based interventions, rather than restricting their practice to more his- torical roles of risk assessment, mental state examination and generic support. Mental health nurses offer unique contributions to the delivery of talk based interventions (Hurley, 2009). Despite this, perceptions of some referrers toward mental health nurse capability and the funding rules under the MHNIP may be seen as barriers to nurses undertaking such formal talk based therapy roles. Findings show that organisations such as Headspace offer pathways to address these barriers and to entrench talk based therapy roles into wider understandings of mental health nurse identity, to the benefit of service users.

A common understanding in mental health care is that good medicine (and arguably good allied health, nursing and social care) is founded on a thorough assessment, leading to a diagnosis which then dictates or at least informs what kind of treatment or care ought to be provided. However, this simple heuristic is problematic in psychiatry. Psychiatric diagnosis are essentially descriptive labels which have utility for researchers and health professionals in terms of communication, but they don't presume anything (although we often assume much) about aetiology or prognosis and therefore are a poor foundation for treatment and care. Much has also been made of the damaging, stigmatising effects of being psychiatrically labelled and engulfed in a patient role. Nevertheless a commitment to the ethical principle of veracity and to evidence based practices such as psycho-education seem to require that service users be informed of and educated about their diagnosis. This presentation considers a different problem associated with telling people what is wrong with them. That is, naively following the assessment-diagnosis-treatment heuristic may perpetuate forms of epistemic injustice: Diminishing the person as an informant and person with capacities (a grievous harm in it-self) but it may also prematurely foreclose on opportunities to make sense of experience and discover the best solutions to problems. Whether we share a psychiatric diagnosis or not with service users (and I'm not suggesting that communicating diagnosis is inherently wrong) it is crucially important for the wellbeing and recovery of service users that diagnosis are offered tentatively and that both they and health professionals engage in an ongoing process of exploration and discovery.

The stigmatising, dehumanising and destructive side of institutional care (including psychiatric care) has been the subject of extensive and sustained critique for many years. This has fuelled a drive towards reform in systems of psychiatric care and a renegotiation of the social contract between health professionals and service users. Nevertheless, people who are presumed to have a mental illness continue to suffer many indignities and injustices at the hands of those that purport to care for them. This paper draws on the worker of Fricker (2007) and outlines two forms of epistemic injustice and how they may apply in everyday mental health care and impede genuine and positive mental health reform. The first 'testimonial injustice' occurs when a people's testimony is given reduced credibility, thus diminishing them as an informant or giver of knowledge. The second which is elaborated in more detail is 'hermeneutical injustice', or a social situation in which a collective hermeneutical gap prevents a person from making sense of an experience which is strongly in their interests to render intelligible. The paper then considers how nurses can engage in mental health care that embodies and promotes justice.
Fricker, M. (2007). Epistemic Injustice: Power and the Ethics of Knowing. Oxford: Oxford University Press.

Objectives Research involving people who may be suicidal is fraught with ethical problems. There are few guidelines to assist researchers or review boards clarify and negotiate issues that may be specific to suicide research. This survey aim to describe these problems and how they might be resolved.
Design: Experienced researchers (identified via published research) and ethics committee members were invited to complete an on-line survey addressing the risks, benefits and ethical problems associated with suicide research.
Methods: Twenty eight researchers and 125 ethics committee members participated in the survey from Australia, New Zealand, Canada the United Kingdom and Ireland. Findings were aggregated into themes using an inductive form or content analysis.
Results: A range of ethical problems were anticipated and addressed by researchers. Concerns of ethics committees centred on accessing the population, potential harm to participants or the researcher, researcher competency, maintaining confidentiality, providing support to participants and responding sensitively to the needs of family.
Conclusions: Ethical research with people who may be suicidal requires both procedures to protect participants, and consideration of ethics as an ongoing negotiated process.

Suicide is a pressing social concern but engaging with suicidal people in research is fraught with ethical difficulties. This paper presents the findings of a web based survey of experienced suicide researchers and human ethics committee members (from Ireland, the United Kingdom, Canada, Australia and New Zealand) on the ethical problems and ethical practice involved with working with people who may be suicidal. Ethical research involving suicidal people requires both procedures to protect participants, and consideration of ethics as an ongoing negotiated process. The findings provide salient pointers for researchers and practitioners to consider in their work with suicidal persons.

Introduction This research project examines communication processes between clinical supervisors and supervisees who engage in an online supervisory relationship via the Internet. An international team of nine researchers, comprising professionals and academics from a wide range of disciplines, collaborated in developing a long term research study to: explore the experience of computer mediated clinical supervision; establish the extent to which online clinical supervision matches the expectations of supervisees and meet professional standards; describe differences between computer mediated clinical supervision and face-to-face clinical supervision; and evaluate how communication practices are adapted using different computer applications in the process of online clinical supervision.
Method This presentation will illustrate: the development of the diverse research team; development of an ethical research proposal via collaboration through listserv communication; development of the project website (www.online-supervision.net); promotion of the research website; participants registering and indicating their suitability for inclusion or exclusion through website submission form (and quality control/training of participants); development of disclaimers and informed consent content; and technological design for matching supervisees within peer groups or and/or matching supervisees with supervisors.
Results It is anticipated that from the 80+ mental health professionals who have registered an interest in participating as of January 2003, a significant number will go onto become research subjects, along with other recruits, to form small supervision groups and dyads. A five-phase design encompasses an initial phase of data collection to enable the team to match participants, followed by four follow-up phases at three-month intervals of web based questionnaire completion about their experience of online supervision for analysis. Results of phase one of the research project and subsequent matching of participants and their expectations about the online supervisory relationship are presented as the result of the methodological techniques demonstrated.

This paper examines the ethical implications of nurses as tools, that is nurses carrying out the delegated or instrumental work of others. It is proposed that nursings' instrumental relationship with medicine, has in some instances led to an ethos, or moral climate which legitimises excluding nurses and patients from moral decision making and silences the moral voice of nursing. Nursings' involvement with compulsory psychiatric treatment is examined as a particularly problematic area of practice in terms of the legal requirement to carry out "doctor's orders" and exclusion from dialogue about the terms of treatment. Treating nurses as mere tools is challenged as unethical and the facilitation of a new health care ethos founded on values of collaboration, relationship and inclusion is proposed as a moral imperative for ethical health care.

Most people who are in the business of trying to help people deal with difficulties in their lives, their relationships and with negotiating health, welfare and justice systems do so with the best of intentions. However, as the proverb goes 'the road to hell is paved with good intentions'. The importance of this edited book by Phil Barker is the unrelenting subtext that the best of intentions are insufficient to be ethical in the helping professions….