Developing the therapeutic alliance in acute mental health care

The establishment of a good working relationship, or therapeutic alliance, is seen as a key indicator of good outcome in all forms of psychological therapy. Such a relationship, however, is difficult to establish in acute mental health, when the patient may both need and fear therapeutic contact. The patient care plan can give the appearance of a positive working alliance when this is not truly established. The Care Plan Approach can prioritize case management and risk assessment over treatment. A good therapeutic alliance can often be achieved in times of acute crisis, but only when the difficulties in so doing are recognized and acknowledged. The distinction between benign and malign dependency can be a useful way of conceptualizing therapeutic and non‐therapeutic factors in acute care. Apparently progressive paradigms in mental health care serve to deny the inherent difficulties and conflicts involved in establishing a therapeutic alliance in cases of severe mental illness. Developing a genuine therapeutic culture in acute mental health requires that organizational structures and protocols are clinically informed and are congruent with the therapeutic ethos desired. Examples from a recently established Acute Day Hospital will illustrate how a psychodynamically‐informed group‐based treatment can be effective in developing the therapeutic alliance. I will focus on Psychiatric Nursing, although I hope that the content of the paper is more widely applicable.     

Good Practice in Transcultural Counselling: An Asian Perspective

In Britain today, counsellors and therapists often work with people from a diverse range of ethnic groups whose cultures are substantially different from their own. There is increasing concern that people from black and ethnic communities have limited access to appropriate services—despite service planners' and providers' statements that mental health services are being restructured to become more sensitive, relevant and meaningful to these communities. This paper is an attempt to redress the balance with an emphasis on the therapeutic needs of South Asian communities. It aims to challenge assumptions and beliefs held by therapists and counsellors, question therapeutic practice based within a white, middle-class ideology, raise awareness of an 'Asian' perspective in therapy, and provide some guidelines for good practice in transcultural counselling.     

Clinical controversy and the domains of scientific evidence

The diversity of mental health care "schools" or therapeutic perspectives poses problems in selecting and using any single therapeutic perspective. This article describes the genesis of clinical controversy--that is, how two or more therapeutic perspectives of the same clinical situation can be so different yet not necessarily differ in outcome. Ideas drawn from contemporary philosophy of science show how different "schools" derive separate, incompatible sets of scientific evidence from the same clinical situation. The school or theory determines (in part) not just what evidence is used, but what evidence is actually perceived. The authors conclude by recommending a pluralistic approach to mental health care; they map out some consequences of this pluralism and suggest some strategies for minimizing the disadvantages of "mixing and matching" therapeutic perspectives.     

The common sense of counseling psychology: introducing the Common-Sense Model of self-regulation

Abstract

The goal of therapy is typically to improve clients’ self-management of their problems, not only during the course of therapy but also after therapy ends. Although it seems obvious that therapists are interested in improving clients’ self-management, the psychotherapy literature has little to say on the topic. This article introduces Leventhal’s Common-Sense Model of Self-Regulation, a theoretical model of the self-management of health, and applies the model to the therapeutic process. The Common-Sense Model proposes that people develop illness representations of health threats and these illness representations guide self-management. The model has primarily been used to understand how people self-manage physical health problems, we suggest it may also be useful to understand self-management of mental health problems. The Common-Sense Model’s strengths-based perspective is a natural fit for the work of counseling psychologists. The model has important practical implications for addressing how clients understand mental health problems over the course of treatment and self-manage these problems during and after treatment.     

Client or patient? Contrasts between medical and counselling models of confidentiality

Conflicts can arise within counseling in primary care settings over issues of client confidentiality as perceived from a therapeutic as opposed to medical perspective. ‘Ideal types’ of counseling confidentiality and medical confidentiality are compared, according to a proposed structural model of confidentiality. In contrast with a therapeutic concept of confidentiality as an interpersonal contract between client and counsellor, a structural model of confidentiality appropriate to medical and primary care settings would include reference to crucial aspects such as risk assessment, and the sharing of client information within a multi-disciplinary team. The client-centred counselling model of confidentiality is then explored with reference to the Derbyshire Inquiry Report on the mental health care provided for a client with psychiatric problems. The limitations of adopting an exclusive client-centred counselling approach towards confidentiality in primary care settings are noted, given the requirements of the Care Programme Approach for effective risk assessment and inter-professional liaison in the care of client and patients with psychiatric problems. The potential resultant issues of counsellor and general practitioner liability are identified in relation to complaints systems and the key legal concept of vicarious liability.     

A Public Health Framework for Preventing Mental Disorders in the Context of Pandemics

The COVID-19 pandemic has universally threatened the building blocks of mental health, well-being, and quality of life, namely, expectations of safety, connectedness, hope, and individual and societal efficacy. Consequently, unprecedently large numbers of individuals are significantly stressed and many are at risk for relapse of mental health problems, exacerbations of existing mental and behavioral health problems, and new onset clinical problems. Because of the scope of the problem, a population-based public health perspective is needed, which in the context of disasters has well-established theories and prevention approaches. Public health approaches to disasters and pandemics focus on preventing subclinical problems from becoming clinical disorders, in comparison to clinical care approaches that focus on treating established disorders. Fortunately, specialty care clinicians who typically think about assessing and treating established disorders have the training and clinical competencies to deliver prevention-focused interventions. This paper is designed to help specialty care clinicians who use cognitive-behavioral strategies to understand the biopsychosocial impacts and resource deficits associated with COVID-19-related stressors and the public health perspective to address them. We also provide ways clinicians can help people who are suffering from significant stress and resource deficits bounce back and regain functioning. We describe psychological first aid, stress management, repeated ecological assessment, writing about stressors, problem-solving, and behavioral activation approaches to assist individuals at risk for enduring stress-linked problems.     

A five‐year evaluation of the effectiveness of person‐centred counselling in routine clinical practice in primary care

Counselling is the recommended treatment for individuals with mild to moderate mental health problems of recent onset. In this evaluation of a primary care counselling service offering person‐centred counselling, the Core Outcome Measure (CORE‐OM) was administered at referral and at the beginning and end of therapy. A pre‐post therapy effect size for 697 individuals over a 5 year period was 1.2. This compares with a waitlist (between referral and pre therapy) effect size of 0.24 for 382 individuals over a three year period. The results indicate that person‐centred counselling is effective for clients with common mental health problems, such as anxiety and depression. Effectiveness is not limited to individuals with mild to moderate symptoms of recent onset, but extends to people with moderate to severe symptoms of longer duration.     

Teaching mindfulness to psychotherapists in clinical practice: The Mindful Therapy Programme

Introduction: Initially proposed as a treatment modality for psychological disorders, mindfulness is now being promoted as a means of enhancing both therapist self care and therapeutic efficacy. The degree to which mindfulness can be learned by therapists to manage their own and clients' processes in therapy is as yet unknown. This study examines training outcomes of a standardised introductory mindfulness programme for mental health professionals. Methods: Forty-seven mental health professionals completed an eight-week mindful therapy (MT) training programme and associated measures. Results: Compared with baseline scores, participants demonstrated knowledge acquisition on all measures, including increased mindfulness in clinical work, increased capacity to intentionally invoke mindful states of consciousness, and higher participant ratings of well-being over the course of training sessions. Discussion: This research provides preliminary evidence that a brief, standardised mindfulness training programme can achieve acceptable knowledge and skills outcomes for therapists that can aid their therapeutic practice. Of note, increased ‘therapeutic mindfulness’ in this study resulted from changed mindfulness ‘attitudes’ (i.e. a more accepting and equanimous orientation within therapeutic work) as opposed to a clear demonstration of increased attention-regulation skills. The implications of these and other results for programme development and wider research are discussed.     

Cultural Lens on Mental Illness: Four Clients Share Their Perspectives

People served by mental health providers represent diverse cultural groups. In-depth qualitative interviews were used to collect data to examine: “How do people, diagnosed with a mental illness, perceive their experience in a partial care mental health program from the perspective of their cultural context?” Four participants described cultural identities that included ethnic, health status, and sexual orientation identities. The participants' way of participating in the world was often in conflict with cultural values and expectations of the family and counselors. Cultural competence must include understanding how complex, multiple cultural contexts interact and influence a person's participation in the therapeutic process.     

Mental Health and Spirituality in Later Life: Pastoral Approaches

SUMMARY

This chapter proposes a perspective on providing pastoral care for people at risk of, or who have mental health problems in later life. Two major areas of mental health, depression and dementia are explored, examining their impact on older people and strategies to identify risk in depression, and signs indicating need for pastoral intervention in depression and/or dementia. The work from two studies that examine issues for meaning of people, the first for older people living independently and the second in residential care, form the basis of the material presented in this chapter. It is maintained that pastoral interventions may greatly improve quality of life for these people, their families and carers.¹     

Occupational Therapy's Emerging Role With Transitioning Adolescents in Foster Care

The American Occupational Therapy Association's Centennial Vision advocates for an emphasis on intervention and prevention services for children, young people, the aging, and those with severe and persistent mental illness. This article discusses mental health issues among adolescents in foster care, a population that would greatly benefit from occupational therapy services emphasizing skill development in the areas of independent living, vocation, and health. Additionally, current intervention modalities used by other disciplines with adolescents in foster care are explored. Finally, a pilot study demonstrating the opportunities for occupational therapists to influence the long-term outcomes of adolescents in foster care is described.     

Limitations of Mental Health Case Management: A Rational Emotive and Cognitive Therapy Perspective

Since the closure of many psychiatric hospitals, case management has come to be accepted worldwide as a method of community care for the seriously mentally ill. Although case management has many commendable values, it falls short of providing a comprehensive treatment. It focuses almost exclusively on environmental interventions and largely ignores psychological elements of an individual's functioning. In particular, case management rarely provides clients with evidence-based therapy techniques, such as those developed from a cognitive-behavioral perspective. Consequently, clients with mental illness are not being provided with skills which could help them systematically reduce their emotional disturbance. It is hypothesized that the effectiveness of mental health case management may be enhanced by incorporating evidence-based psychological therapies within a community care model.     

A qualitative study of primary health care access, barriers and satisfaction among people with mental illness

Research has found that a substantial proportion of individuals with mental illness have high morbidity and mortality rates, and high under-diagnosis of major physical illnesses. Furthermore, people with a mental illness tend not to seek out or utilise health care services. The reasons for the negative attitudes and behaviour towards health care services among this population have not been investigated. This paper presents findings from a study that investigated the health care service needs of people with mental illness (n = 20), and views from health care providers (n = 16) regarding access to these services by people with a mental illness. Results indicated that psychiatric patients identified a range of barriers to their health care usage and low levels of health care satisfaction. These views were shared with health care professionals. Reasons for these findings and strategies to address these problems so that there is better access to health care services for people with mental illness are discussed.     

Seeking for Authentic Self in Community

Misconceptions about counseling, being anxious about losing face, not having enough resources, and losing the traditional therapeutic community which Koreans once had are the key reasons for the increase of mental problems among Koreans. The author explores the Korean mindset and thus is able to provide more effective and adequate counseling services for people from a Korean cultural background. This article emphasizes the importance of healing community in Korean culture and provides some practical suggestions for the psychological well-being of Koreans from a pastoral counseling perspective.     

Family-Involved Mental Health Care Among OEF/OIF Veterans With and Without PTSD Using VHA Administrative Records

Prior research indicates that veterans are interested in including family members in health care and that family-inclusive mental health treatment can improve treatment outcomes. Consequently, the Veterans Health Administration’s (VHA) directive requires providers to offer family-inclusive mental health services to veterans. However, the extent to which veterans engage in family-inclusive mental health services at the VHA remains unclear. Using data from a longitudinal registry of male and female veterans with and without posttraumatic stress disorder, we examined the extent to which veterans included family members in their mental health care and predictors of engagement in family-involved therapy visits using VHA administrative records over a 5-year time span. Of the 1,329 veterans who received mental health care during the study, 8.4% received a family therapy visit—the number of visits per veteran ranged from 1 to 34. Results from logistic regressions indicate that relative to White veterans, Black veterans were 61.0% less likely to receive a family-involved therapy visit. Married veterans or veterans living with a partner, and veterans with poor romantic relationship functioning, were more likely to receive a family-involved therapy visit. These findings indicate that only a small percentage of veterans received a family therapy visit across 5 years. Efforts to understand barriers to family-involved therapy visits and strategies to increase engagement in family-involved visits may improve clinical outcomes and promote patient-centered care.     

Addressing social determinants of mental health in therapy: A thematic synthesis

Background

The importance of addressing social determinants of mental health in therapy is well-documented. However, there appears to be limited research on what this actually involves in practice and how best to prepare therapists to work with individuals experiencing adverse social determinants.

Aims

The aim of this review was to draw implications for practice and training from reviewing research on addressing social determinants of mental health in therapy.

Methodology

A qualitative systematic review of the research on addressing social determinants of mental health in therapy was conducted, extracting papers from eight databases: Cochrane Library, ASSIA, CINAHL Plus, PsycInfo, Psychoanalytic Electronic Publishing, Science Direct, Scopus and Web of Science. Out of 127 papers found, five met the eligibility criteria and were quality-assessed and analysed thematically.

Findings

The thematic synthesis generated three main themes: “the therapeutic relationship,” “adapting to client context” and “community as a resource,” with eight subthemes.

Conclusion

This thematic synthesis highlights the importance of the therapeutic relationship and adapting mental health support to client frame of reference and context to address social determinants of mental health in therapy. It emphasises community as a helpful resource for informing training and therapeutic interventions, as well as a significant resource for people experiencing adverse social determinants.     

Collaborative Communication Between Psychologists and Primary Care Providers

Psychologists frequently collaborate in the care of patients managed in primary care. Communication with a patient’s primary care team is important to ensure coordination and continuity of care. The communication is far from seamless. Although The Health Information Privacy and Portability Act (HIPPA) is designed to promote sharing of clinical information while protecting patient confidentiality, unique problems arise when mental health records are included. Mental health records are subject to different regulations to protect the patient’s confidentiality. Thus, what is communicated and how it will be accomplished are challenges. Further, psychologists and primary care providers often view documentation differently, resulting in different styles of documenting that may also impede coordinated care. Increasingly, health care systems are moving toward electronic medical records, creating greater opportunities for an integrated record. Improved communication through the record can keep other providers abreast of the mental health care being provided as well as suggestions they can use to reinforce the mental health care treatment plan.     

Examining Factors Associated with Primary Care and Continuity of Care Among Adults with Severe Mental Illness

A number of studies have consistently reported that there is a greater prevalence of mental illness among the most socioeconomically disadvantaged. At the same time, there is evidence that services are not optimally accessed by the most socioeconomically disadvantaged; the most in need of care are also the most likely to have unmet healthcare needs. Of people with mental illnesses, those with severe mental illnesses (SMI) are the most at risk of poverty and the least likely to have optimal care. In the past, specialized community mental health services have been identified as the primary provider for people with SMI. However, there is growing interest in using the primary care setting as the main source of mental health care where both medical treatment and psychotherapy can be accessed. In this paper, we examine factors related to primary care use (and in turn, pharmacologic and psychotherapies) for people who are socioeconomically disadvantaged and who have a SMI.     

Mental Health Problems,Recovery, and the Impact of Green Care Services: A Qualitative,Participant-Focused Approach

This study aimed at gaining knowledge of users' experience of green care services (interventions using nature to improve health) for people with mental health or drug problems. Data were obtained from interviews with 20 participants in green care services and were analyzed qualitatively. Findings revealed that work in a social context close to nature and work with animals increased mastery and meaningfulness. Participation resulted in personal changes, new practical skills, improved social networks, and feelings of well-being. There appears to be powerful potential in using green care services as a recovery tool for people with mental health or drug-related problems.     

Kunsttherapie

Art therapy uses all kinds of art media for psychotherapeutic purposes, such as painting, drawing, moulding, constructing, sculpturing and building. Therapeutically driven art therapies are aimed at the enhancement of personal resources, motivational and intentional improvement, coping and more adaptive interpersonal functioning. Every psychotherapeutic and psychiatric setting can integrate art therapy, and its use in different types of mental disorder has been extensively described. Neurobiological aspects of creativity and effects of the therapeutic relationship are discussed as being involved in the effectiveness of art therapy. There is growing evidence for its effectiveness. Art therapy can contribute to diagnostic and therapeutic procedures. A comprehensive table of art therapy interventions which can be applied within a psychotherapeutic setting is presented.