Conceptualizing the peer contribution in Open Dialogue practice.

In English mental health services, people with their own experience of mental distress have trained as Open Dialogue practitioners and have been employed as peer practitioners, co-working as equals alongside workers with professional backgrounds in Network Meetings. The conceptual underpinnings of the peer practitioner role have been drawn from the principles and relational approach of Intentional Peer Support. These have significant similarities with Open Dialogue, in terms of philosophical and theoretical orientations, with a particular focus on what happens in the "between" of a relational encounter. However, there are also significant differences in how practice principles are conceptualized, particularly around areas such as mutuality and self-disclosure. This article offers an analysis of this conceptual territory drawing on the relevant literature. This is then taken forward with the teasing out of specific practice principles that capture the unique contribution that peer practitioners can bring to Open Dialogue practice. These are derived through discussions that took place in an Action Learning Set for peer practitioners who have been involved in delivering Open Dialogue services in mainstream mental health service settings. This was part of a wider research study entitled Open Dialogue: Development and Evaluation of a Social Network Intervention for Severe Mental Illness (ODDESSI). The principles address how peer practitioners may be particularly well-placed to offer attunement, validation, connection and mutuality, and self-disclosure - and hence how they may be able to contribute an additional dimension to dialogical practice.

A crisis of meaning: can 'schizophrenia' survive in the 21st century?

Both within clinical and wider societal discourses, the term 'schizophrenia' has achieved considerable potency as a signifier, privileging particular conceptual frames for understanding and responding to mental distress. However, its status has been subject to instability, as it has lacked indisputable biological correlates that would anchor its place within the canon of medical diagnosis. Informed by a semiotic perspective, this paper focuses on its recent history: how 'schizophrenia' has been claimed, appropriated and contested-and how this connects with its earlier history of signification. It also explores how the dominance of this signifier has influenced the ways in which people with the diagnosis may find themselves constructed in their interactions with professionals, family and wider society, and hence how they may come to see themselves. It is argued that, from a point in the 1990s when 'schizophrenia' had achieved an almost iconic status, the term is now subject to greater instability, with concerns and challenges being raised from both within and outside psychiatry. On the one hand, this uncertainty has triggered a 'calls to arms' from those within the psychiatric establishment who see diagnoses such as 'schizophrenia' as crucial to their professional identity and status. On the other hand, this has created spaces for new conversations and alliances between elements within neurology, psychiatry, social work and other professions, and between these and service users. Some of these conversations are casting doubt on the validity and utility of 'schizophrenia' as a construct, and are beginning to posit alternative regimes of signification.

The role of family carers in the use of personal budgets by people with mental health problems.

Personal budgets aim to increase choice and independence for people with social care needs but they remain underused by people with mental health problems compared to other disability groups. The use of personal budgets may impact on families in a variety of ways, both positive and negative. This paper draws on interviews, undertaken in 2012-2013 with 18 family carers and 12 mental health service users, that explored experiences of family involvement in accessing and managing personal budgets for a person with mental health-related social care needs. The sample was drawn from three sites across England, with additional carers being recruited via voluntary sector networks. Our findings show that for many people with severe mental health needs who lack motivation and confidence to negotiate access to personal budgets, carers may provide the necessary support to enable them to benefit from this form of social care support. We illustrate the role carers may play in initiating, pursuing and maximising the level of support available through personal budgets. However, some carers interviewed considered that personal budget funding was reduced because of practitioners' assumptions about carers' willingness and ability to provide support. We also report perceived tensions between family carers and practitioners around appropriate involvement in decision-making. The study findings have implications for local authorities, practitioners and family carers in supporting the involvement of family carers in support for people with severe mental health problems.

Outcomes from personal budgets in mental health: service users' experiences in three English local authorities.

BACKGROUND: In England, personal budgets are offered to eligible people with severe mental health problems to enable them to purchase what is helpful for their quality of life or recovery. However, in-depth insight into people's own perceptions of the outcomes is lacking. AIMS: To investigate people's own reporting of outcomes from using personal budgets in relation to social care needs arising from severe mental health problems. METHOD: A convenience sample of 47 individuals receiving personal budgets was recruited from three English local authorities. In-depth semi-structured interviews were subject to thematic framework analysis. RESULTS: Most participants identified positive outcomes across domains interconnected through individual life circumstances, with mental health and wellbeing, social participation and relationships, and confidence and skills most commonly reported. Some needed more support than others to identify goals and make use of the personal budget to take a more active part in the society. CONCLUSIONS: Personal budgets can enable people to achieve outcomes that are relevant to them in the context of their lives, particularly through enhancing their wellbeing and social participation. Consideration should be given to distinguishing those individuals potentially requiring more support for engagement from those who can engage more independently to identify and pursue their goals.

Implementing personalisation in integrated mental health teams in England.

This article explores how role boundaries and professional priorities in integrated mental health teams have impacted on the implementation of personalised approaches to social care support. We focus on the use of personal budgets to meet mental health-related social care needs as a key mechanism for personalised care. Drawing on 28 qualitative interviews with mental health practitioners from three local authorities in England undertaken in 2013, we report nurses', social workers', and occupational therapists' attitudes towards, and engagement with, personal budgets. Professional boundaries and competing priorities heavily influenced the extent to which personal budgets were perceived as a legitimate part of their roles. Across different professional groups, a sense emerged that personal budgets should be somebody else's job. A focus on attention to treatment, stability, and risk management often resulted in low prioritisation of personal budgets and led practitioners to avoid recommending them or to exclude service users from the process as a way to save time. Implications of the dominant medical model and the protection of traditional professional roles for the implementation of new, person-centred models of practice are discussed.

Fit for purpose? Validation of a conceptual framework for personal recovery with current mental health consumers.

OBJECTIVE: Mental health services in the UK, Australia and other Anglophone countries have moved towards supporting personal recovery as a primary orientation. To provide an empirically grounded foundation to identify and evaluate recovery-oriented interventions, we previously published a conceptual framework of personal recovery based on a systematic review and narrative synthesis of existing models. Our objective was to test the validity and relevance of this framework for people currently using mental health services. METHOD: Seven focus groups were conducted with 48 current mental health consumers in three NHS trusts across England, as part of the REFOCUS Trial. Consumers were asked about the meaning and their experience of personal recovery. Deductive and inductive thematic analysis applying a constant comparison approach was used to analyse the data. The analysis aimed to explore the validity of the categories within the conceptual framework, and to highlight any areas of difference between the conceptual framework and the themes generated from new data collected from the focus groups. RESULTS: Both the inductive and deductive analysis broadly validated the conceptual framework, with the super-ordinate categories Connectedness, Hope and optimism, Identity, Meaning and purpose, and Empowerment (CHIME) evident in the analysis. Three areas of difference were, however, apparent in the inductive analysis. These included practical support; a greater emphasis on issues around diagnosis and medication; and scepticism surrounding recovery. CONCLUSIONS: This study suggests that the conceptual framework of personal recovery provides a defensible theoretical base for clinical and research purposes which is valid for use with current consumers. However, the three areas of difference further stress the individual nature of recovery and the need for an understanding of the population and context under investigation.

Implementing personalisation for people with mental health problems: a comparative case study of four local authorities in England.

BACKGROUND: Enhancing choice and control for people using services is a mental health and social-care service priority in England. Personalisation is a new policy and practice for delivery of social-care services where eligible adults are allocated a personal budget to spend to meet their agreed support needs. AIMS: To describe approaches to introducing personal budgets to people with severe and enduring mental health needs, and to identify facilitators or barriers encountered. METHOD: Within four English local authority (LA) areas, purposively selected to provide maximum variation, semi-structured interviews were undertaken with 58 participants from LAs, NHS trusts and third-sector organisations. An Interpretive Framework analysis considered within- and across-site insights. RESULTS: Issues arising from the implementation of personalisation for people with mental health needs are presented under two general themes: "responsibility and power" and "vision and leadership". Key challenges identified were complexities of working across NHS and LAs, the importance of effective leadership and engagement with service user representatives. CONCLUSIONS: Implementing personal budgets in mental health requires effective engagement of health and social-care systems. Change processes need strong leadership, clear vision and personal commitment, with ownership by all key stakeholders, including front-line practitioners.

Toward a new way of relating: an evaluation of recovery training delivered jointly to service users and staff.

AIM: This paper explores an innovative approach to recovery training in which the medium of delivery - as much as the actual content of what was delivered - challenged the conventional construction of professional relationships. METHODOLOGY: The training group comprised service users together with the practitioners who normally worked with them and would continue to do so. The paper examines the staff experiences of the training and the impact on their practice through qualitative interviews conducted 6 months post-training with a sample of four staff participants. FINDINGS: The thematic analysis of the interviews demonstrated that this approach could be a powerful experience that brought about lasting changes in working relationships and professional identities. Particular themes that emerged included challenging power relationships and the value of the trainers disclosing their own lived experience and recovery narratives in creating a "safe space" for collaborative learning. IMPLICATIONS FOR FUTURE PRACTICE: This approach demonstrated the potential to be transformative for staff and their relationships with service users, although care may need to be exercised when offering it to staff with little prior exposure to recovery-oriented practice.

The contribution of advisory committees and public involvement to large studies: case study.

BACKGROUND: Many large studies have complex advisory committee structures, yet there is no empirical evidence regarding their optimal composition, scope and contribution. The aim of this study was to inform the committee and advice infrastructure for future research studies. METHODS: In the context of a five-year study funded by the UK National Institute for Health Research, three advisory committees were formed. In addition, advice was obtained from individual experts. All recommendations received in the start-up phase (first seven months) of the study were recorded, along with the decision about implementation of the recommendation. A particular focus was on the impact of public involvement. RESULTS: A total of 172 recommendations were made, including 70 from 20 individual experts. The recommendations were grouped into five emergent themes: Scientific, Pragmatic, Resources, Committee and Collaboration. Most recommendations related to strengthening existing components or adding new components to the study protocol. Very few recommendations either proposed removing study components or contradicted other recommendations. Three 'implementation criteria' were identified: scientific value, pragmatic feasibility, and paradigmatic consistency. 103 (60%) of recommendations were implemented and 25 (15%) were not implemented. The benefits identified by the research team were improved quality and confidence, and the costs were increased cognitive demands, protocol revision time, and slower progress. CONCLUSIONS: The findings are discussed in the context of the wider literature on public involvement in research. Six recommendations are identified. First, have a clear rationale for each advisory committee expressed as terms of reference, and consider the best balance between committees and individual consultation with experts. Second, an early concern of committees is inter-committee communication, so consider cross-representation and copying minutes between committees. Third, match the scope of advisory committees to the study, with a less complex advisory structure for studies with more finalised designs. Fourth, public involvement has a mixed impact, and relies on relationships of trust, which take time to develop. Fifth, carefully consider the match between the scientific paradigm applied in the study and the contribution of different types of knowledge and expertise, and how this will impact on possibilities for taking on advice. Finally, responding to recommendations uses up research team resources, and the costs can be reduced by using the three implementation criteria.