Corrective biology: psychosomatics in and as neuropsychoanalysis.

This article analyses how and with what consequences body-mind relations (the sphere of the psychosomatic) are being modelled in the 21st century through considering the interdiscipline of neuropsychoanalysis. The promise of the term psychosomatic lies in its efforts to rework standard, bifurcated models of mind and body: somatic acts are simultaneously psychic acts. But neuropsychoanalysis, as it brings the neurosciences and psychoanalysis together to model an embodied 'MindBrain', ends up evacuating another potent characteristic found in much of the psychosomatic tradition-its refusal to adjudicate, a priori, what counts as the adaptive or well-regulated subject. The psychosomatic problem in psychoanalysis profoundly disturbs everyday models of functionality, adaptation and agency, by positing the psyche as an 'other' of the physiological within the physiological. By contrast, neuropsychoanalysis ends up parsing too easily the healthy from the pathological body, such that it is only the latter that is subject to forces that work against self-preservation and self-regulation. In so doing, neuropsychoanalysis recasts the radical problematic that the psychosomatic installed for psychoanalysis in the direction of a corrective biology. This corrective biology is given form in two ways: (1) through translating the Freudian drive-that unruly and foundational concept which addresses the difficult articulation of soma and psyche-into a series of Basic Emotion Systems modelled by the affective neuroscientist Jaak Panksepp and (2) through resituating and quarantining the troubling, non-adaptive aspects of the Freudian psyche within the domain of addiction. That easy separation between the healthy and the pathological is all too often found in current descriptions of healthcare and patient encounters. The article refuses it and calls for the revivification of other ways of thinking about how human subjects-psychosomatic organisms-find ways to live, and to die.

Toward Co-productive Learning? The Exchange Network as Experimental Space.

Policy around patient and public involvement (PPI) in the production, design and delivery of health services, and research remains difficult to implement. Consequently, in the UK and elsewhere, recent years have seen a proliferation of toolkits, training, and guidelines for supporting good practice in PPI. However, such instruments rarely engage with the power asymmetries shaping the terrain of collaboration in research and healthcare provision. Toolkits and standards may tell us little about how different actors can be enabled to reflect on and negotiate such asymmetries, nor on how they may effectively challenge what count as legitimate forms of knowledge and expertise. To understand this, we need to turn our attention to the relational dynamic of collaboration itself. In this paper we present the development of the Exchange Network, an experimental learning space deliberately designed to foreground, and work on this relational dynamic in healthcare research and quality improvement. The Network brings together diverse actors (researchers, clinicians, patients, carers, and managers) for structured "events" which are not internal to particular research or improvement projects but subsist at a distance from these. Such events thus temporarily suspend the role allocation, structure, targets, and other pragmatic constraints of such projects. We discuss how Exchange Network participants make use of action learning techniques to reflect critically on such constraints; how they generate a "knowledge space" in which they can rehearse and test a capacity for dialogue: an encounter between potentially conflictual forms of knowledge. We suggest that Exchange Network events, by explicitly attending to the dynamics and tensions of collaboration, may enable participants to collectively challenge organizational norms and expectations and to seed capacities for learning, as well as generate new forms of mutuality and care.

Showing the Unsayable: Participatory Visual Approaches and the Constitution of 'Patient Experience' in Healthcare Quality Improvement.

This article considers the strengths and potential contributions of participatory visual methods for healthcare quality improvement research. It argues that such approaches may enable us to expand our understanding of 'patient experience' and of its potential for generating new knowledge for health systems. In particular, they may open up dimensions of people's engagement with services and treatments which exceed both the declarative nature of responses to questionnaires and the narrative sequencing of self reports gathered through qualitative interviewing. I will suggest that working with such methods may necessitate a more reflexive approach to the constitution of evidence in quality improvement work. To this end, the article will first consider the emerging rationale for the use of visual participatory methods in improvement before outlining the implications of two related approaches-photo-elicitation and PhotoVoice-for the constitution of 'experience'. It will then move to a participatory model for healthcare improvement work, Experience Based Co-Design (EBCD). It will argue that EBCD exemplifies both the strengths and the limitations of adequating visual participatory approaches to quality improvement ends. The article will conclude with a critical reflection on a small photographic study, in which the author participated, and which sought to harness service user perspectives for the design of psychiatric facilities, as a way of considering the potential contribution of visual participatory methods for quality improvement.

Design in mind: eliciting service user and frontline staff perspectives on psychiatric ward design through participatory methods.

BACKGROUND: Psychiatric ward design may make an important contribution to patient outcomes and well-being. However, research is hampered by an inability to assess its effects robustly. This paper reports on a study which deployed innovative methods to capture service user and staff perceptions of ward design. METHOD: User generated measures of the impact of ward design were developed and tested on four acute adult wards using participatory methodology. Additionally, inpatients took photographs to illustrate their experience of the space in two wards. Data were compared across wards. RESULTS: Satisfactory reliability indices emerged based on both service user and staff responses. Black and minority ethnic (BME) service users and those with a psychosis spectrum diagnosis have more positive views of the ward layout and fixtures. Staff members have more positive views than service users, while priorities of staff and service users differ. Inpatient photographs prioritise hygiene, privacy and control and address symbolic aspects of the ward environment. CONCLUSIONS: Participatory and visual methodologies can provide robust tools for an evaluation of the impact of psychiatric ward design on users.

Service users' and carers' views on research towards stratified medicine in psychiatry: a qualitative study.

BACKGROUND: Approximately 30% of people with a diagnosis of schizophrenia receive little to no benefit from current medications. There is therefore an urgent need to develop more precisely targeted and effective treatments. Identifying biomarkers to predict response to treatment and stratify patients into groups may be a way forward. However, we know little about service users' and carers' attitudes regarding such a 'stratified medicine' approach for psychiatry-nor how this might impact on their willingness to participate in stratified medicine research. This paper presents psychiatric service user and carer views on research to develop stratified medicine for treatment resistant schizophrenia, and explores the conditions under which people would be prepared to participate in a trial and their willingness to undergo various research procedures. METHODS: Participatory methods were used throughout. A consultation was undertaken with an existing Service User Advisory Group (SUAG) in order to establish a topic guide. Service user focus groups were then conducted by service user researchers in Manchester, London and Edinburgh (totalling 18 people) and one carer focus group in London, attended by eight participants. Focus groups were digitally recorded, the transcripts analysed in NVivo 10 using a simple thematic analysis, and quotations de-identified to protect participants. RESULTS: The data reflected enthusiasm for the potential of stratified medicine and both service users and carers demonstrated a strong desire to help others. However, some service users and carers feared poor performance on neuropsychological assessments, and reported that certain medication side effects might discourage them from undergoing procedures demanding immobility and concentration. Concerns were voiced that stratified medicine could encourage an overemphasis on biological symptoms, at the expense of psychosocial factors and subjective experience. CONCLUSIONS: People with experience of treatment resistant schizophrenia would welcome stratified medicine research; however researchers should take into account how such experience might inflect service users' willingness to undergo various procedures in the context of this research. These results reinforce the value of service user perspectives in the development and evaluation of novel treatment approaches.

Staff and service users' views on a 'Consent for Contact' research register within psychosis services: a qualitative study.

BACKGROUND: Recruitment to mental health research can be challenging. 'Consent for Contact' (C4C) is a novel framework which may expedite recruitment and contribute to equitable access to research. This paper discusses stakeholder perspectives on using a C4C model in services for people with psychosis. METHOD: This is a cross sectional study investigating the views of service users and staff using qualitative methods. Eight focus groups were recruited: five with service users (n = 26) and three with clinicians (n = 17). Purposive sampling was applied in order to reflect the local population in terms of ethnicity, experience of psychiatric services and attitudes towards research. RESULTS: Staff and service users alike associated the principle of 'consent for contact' with greater service user autonomy and favourable conditions for research recruitment. Fears around coercion and inappropriate uses of clinical records were common and most marked in service users identifying as having a negative view to research participation. Staff working in inpatient services reported that consenting for future contact might contribute to paranoid ideation. All groups agreed that implementation should highlight safeguards and the opt-in nature of the register. CONCLUSIONS: Staff and service users responded positively to C4C. Clinicians explaining C4C to service users should allay anxieties around coercion, degree of commitment, and use of records. For some service users, researcher access to records is likely to be the most challenging aspect of the consultation.

The psychiatric ward as a therapeutic space: systematic review.

BACKGROUND: Hospital care is still an integral part of mental healthcare services. But the impact of ward design on treatment outcomes is unclear. AIMS: To review the effects of ward design on patient outcomes and patient and staff well-being. METHOD: A systematic review of literature was carried out on Medline, Embase and PsycINFO. Papers on psychogeriatric and child and adolescent wards were excluded as these necessitate specific safety features. RESULTS: Twenty-three papers were identified. No strong causal links between design and clinical outcomes were found. Private spaces and a homely environment may contribute to patient well-being. Different stakeholders may experience ward design in conflicting ways; design has a symbolic and social dimension for patients. CONCLUSIONS: Data on the impact of design on treatment outcomes are inconclusive. Rigorous randomised controlled trials, qualitative studies and novel methods are called for. Different stakeholders' responses to the ward as a symbolic environment merit further investigation.