'Dignity and respect': An example of service user leadership and co-production in mental health research.

This paper explores the methodological aspects of a user-led study investigating mental health service user experiences of targeted violence and abuse (often called 'hate crime'). 'Keeping Control' was a 16-month qualitative study, undertaken in the context of adult safeguarding reforms in England. By collecting data on service user concepts and experiences, the research sought to address a gap in research and practice knowledge relating to targeted violence, abuse and hostility against people with mental health problems. In this paper, we discuss the significance of the design and methodology used for this study, with a particular focus on the interviews with service users. The research was both user-led and carried out in collaboration with practitioners and academics, a form of research co-production. Our aim is to inform researchers, practitioners and policymakers about the value of user leadership in co-productive research with practitioners, particularly for a highly sensitive and potentially distressing topic.

The experience of long stay in high and medium secure psychiatric hospitals in England: qualitative study of the patient perspective.

BACKGROUND: Some forensic patients in England remain in secure care for long, possibly unnecessarily prolonged, periods, raising significant ethical and resource issues. Research focused on the patients in secure care has examined quality of life and service provision but not the perspectives of patients experiencing long stays. This study explored how long stay patients experience secure care, what factors they felt influenced long stay, and its impact upon treatment engagement and motivation to progress. METHODS: Embedded within a larger epidemiological study, we conducted semi-structured interviews with a purposive sample of forty long stay patients from two high and six medium secure hospitals. Long stay was defined as a 5 years stay in medium secure care or 10 years in high secure care, or 15 years in a combination of high and medium secure. Transcripts were subject to thematic analysis, and narrative analysis at individual case level to explore the relationship between emergent themes. RESULTS: Four themes emerged illustrating participants' attribution, outlook, approach, and readiness for change. A typology of four long stay stances was developed (dynamic acceptance, dynamic resistance, static acceptance, static resistance). These illustrate differences in the extent to which participants believed being in secure care helped them to get better, and actively work towards progression and leaving secure care. There were considerable differences in how patients adopting these stances attributed the reasons for their long stay, they viewed their future, and their motivation to progress. Negative perceptions arose from excessive restrictions, treatment repetition and changes in therapeutic relationships, leading some patients to exhibiting tokenistic engagement and low motivation to progress. CONCLUSIONS: Planning care for long stay patients in secure psychiatric settings should take account of the differing stances patient's adopt towards engagement and progression. Service providers should be mindful of these stances and provide patients with individualised opportunities to progress through the secure care treatment pathway, avoiding treatment repetition and maintaining continuity in key professional relationships. Refocusing on quality of life may be appropriate for some long-term patients who are unwilling or unable to move on. For some long-term patients, purpose designed long stay setting may be appropriate.

"Keeping Control": A user-led exploratory study of mental health service user experiences of targeted violence and abuse in the context of adult safeguarding in England.

The situation for people with mental health problems as a group of disabled people who experience targeted violence and abuse is a complex one. Disabled people, particularly those with mental health problems, are at higher risk of targeted violence and hostility with few effective evidence-based prevention and protection strategies. Achieving effective safeguarding for adults with mental health problems is characterised by differential attitudes to and understandings of abuse by safeguarding practitioners, as well as systemic issues arising from multi-agency working. "Keeping Control" was a 16-month user-led, co-produced exploratory qualitative study into service user experiences of targeted violence and abuse that was examined in the context of Care Act 2014 adult safeguarding reforms in England. User-controlled interviews of mental health service users (N = 23) explored their experiences and concepts of targeted violence and abuse, prevention and protection. Preliminary findings from these interviews were discussed in adult safeguarding and mental health stakeholder and practitioner focus groups (N = 46). The data were also discussed via two facilitated Twitter chats (responses N = 585 and N = 139). Mental health service users' experiences and concepts of risk from others, vulnerability and neglect can be different to those of practitioners but should be central to adult safeguarding. Histories of trauma, multi-factorial abuse; living with fear and stigma as well as mental distress; the effects of "psychiatric disqualification" and individual blaming should be addressed in adult safeguarding in mental health. Fragmented responses from services can mean a person becomes "lost in the process". Staff can feel disempowered, afraid or lacking in confidence to "speak up" for individuals in complex service systems with poor communication and lines of accountability. Adult safeguarding practitioners and stakeholders need to be confident, accessible and respond quickly to service users reporting incidents of targeted violence and abuse particularly in closed environments such as wards or supported housing.

Characteristics and Pathways of Long-Stay Patients in High and Medium Secure Settings in England; A Secondary Publication From a Large Mixed-Methods Study.

Background: Many patients experience extended stays within forensic care, but the characteristics of long-stay patients are poorly understood. Aims: To describe the characteristics of long-stay patients in high and medium secure settings in England. Method: Detailed file reviews provided clinical, offending and risk data for a large representative sample of 401 forensic patients from 2 of the 3 high secure settings and from 23 of the 57 medium secure settings in England on 1 April 2013. The threshold for long-stay status was defined as 5 years in medium secure care or 10 years in high secure care, or 15 years in a combination of high and medium secure settings. Results: 22% of patients in high security and 18% in medium security met the definition for "long-stay," with 20% staying longer than 20 years. Of the long-stay sample, 58% were violent offenders (22% both sexual and violent), 27% had been convicted for violent or sexual offences whilst in an institutional setting, and 26% had committed a serious assault on staff in the last 5 years. The most prevalent diagnosis was schizophrenia (60%) followed by personality disorder (47%, predominantly antisocial and borderline types); 16% were categorised as having an intellectual disability. Overall, 7% of the long-stay sample had never been convicted of any offence, and 16.5% had no index offence prompting admission. Although some significant differences were found between the high and medium secure samples, there were more similarities than contrasts between these two levels of security. The treatment pathways of these long-stay patients involved multiple moves between settings. An unsuccessful referral to a setting of lower security was recorded over the last 5 years for 33% of the sample. Conclusions: Long-stay patients accounted for one fifth of the forensic inpatient population in England in this representative sample. A significant proportion of this group remain unsettled. High levels of personality pathology and the risk of assaults on staff and others within the care setting are likely to impact on treatment and management. Further research into the treatment pathways of longer stay patients is warranted to understand the complex trajectories of this group.

Developing and Using Vignettes to Explore the Relationship Between Risk Management Practice and Recovery-Oriented Care in Mental Health Services.

There is a lack of literature evaluating the development and use of vignettes to explore contested constructs in qualitative health care research where a conventional interview schedule might impose assumptions on the data collected. We describe the development and validation of vignettes in a study exploring mental health worker and service user understandings of risk and recovery in U.K. mental health services. Focus groups with mental health workers and service users explored study questions from experiential perspectives. Themes identified in the groups were combined with existing empirical literature to develop a set of vignettes. Feedback focus groups were conducted to validate and amend the vignettes. Following use in research interviews, results suggested that the vignettes had successfully elicited data on issues of risk and recovery in mental health services. Further research using creative, comparative methods is needed to fully understand how vignettes can best be used in qualitative health care research.

Mental health service user experiences of targeted violence and hostility and help-seeking in the UK: a scoping review.

BACKGROUND: The aim of this research scoping review was to assemble an evidence base for the UK on mental health service user experiences and perspectives on mental health-related targeted violence and hostility ('disability hate crime'). It also aims to address some of the gaps in the knowledge on risk management, help-seeking and prevention from the perspectives of those who experienced targeted violence and hostility because of their mental health problems or psychiatric status. METHODS: Seven key mental health and social care bibliographic databases were searched for relevant UK research studies from 1990 until 2016. Grey literature was identified through online searches. A scoping review charting approach and thematic analysis methodology were used to analyse the studies. RESULTS: In total 13 studies were finally included, over half of which used survey methods. All studies included people with experiences of mental health problems. The studies provide information on: the types of potential hate crime; indicate where incidents take place; give some insight into the victims' relationship with the perpetrators; the location of incidents as well as the psychological, social, financial and physical impacts on the victim; the types of help-seeking behaviours adopted by the victims; a range coping strategies that people with mental health problems adopted in response to experiences of targeted violence or abuse. CONCLUSION: This scoping review provides a UK-based overview of mental health service user concepts and experiences of mental health-related targeted violence and hostility ('disability hate crime'). It reveals some specific issues relating to mental health and disability hate crime. Further investigation into disability hate crime with a specific focus on mental health is required. This is a UK-based overview, which offers a useful comparator for researchers, practitioners and policy-makers internationally.

The impact of risk management practice upon the implementation of recovery-oriented care in community mental health services: a qualitative investigation.

BACKGROUND: Recovery-oriented care has become guiding principle for mental health policies and practice in the UK and elsewhere. However, a pre-existing culture of risk management practice may impact upon the provision of recovery-oriented mental health services. AIMS: To explore how risk management practice impacts upon the implementation of recovery-oriented care within community mental health services. METHOD: Semi-structured interviews using vignettes were conducted with eight mental health worker and service user dyads. Grounded theory techniques were used to develop explanatory themes. RESULTS: Four themes arose: (1) recovery and positive risk taking; (2) competing frameworks of practice; (3) a hybrid of risk and recovery; (4) real-life recovery in the context of risk. DISCUSSION: In abstract responses to the vignettes, mental health workers described how they would use a positive-risk taking approach in support of recovery. In practice, this was restricted by a risk-averse culture embedded within services. Mental health workers set conditions with which service users complied to gain some responsibility for recovery. CONCLUSION: A lack of strategic guidance at policy level and lack of support and guidance at practice level may result in resistance to implementing ROC in the context of RMP. Recommendations are made for policy, training and future research.

Peer worker roles and risk in mental health services: a qualitative comparative case study.

New peer worker roles are being introduced into mental health services internationally. This paper addresses a lack of research exploring issues of risk in relation to the role. In-depth interviews were carried out with 91 peer workers, service users, staff and managers. A grounded analysis revealed protective practice in minimising risk to peer worker well-being that restricted the sharing of lived experience, and a lack of insight into how peer workers might be involved in formal risk management. Alternatively, analysis revealed potential new understandings of risk management based on the distinctive, experiential knowledge that peer workers brought to the role.

The effects of physical activity on psychological well-being for those with schizophrenia: A systematic review.

This paper systematically reviews the existing evidence of the effects of physical activity on psychological well-being for those with schizophrenia. A search of 15 databases including for example, PsycINFO, SportDiscus, and Science Direct was conducted to identify studies investigating the effects of physical activity on psychological well-being for those with schizophrenia. The included studies were then assessed, extracted, and synthesized. Fifteen studies met the inclusion criteria: 12 quantitative and 3 qualitative. The physical activity interventions lasted between 3 and 20 weeks and included a wide range of physical activities. The instruments used to measure psychological well-being varied across all studies, this along with the variety of study designs made statistical analysis impossible. The findings of this systematic review however, suggest that physical activity has a beneficial effect on some attributes associated with psychological well-being in individuals with schizophrenia.