Mental Health Workers Negotiating Risk on the Frontline

Abstract

Following deinstitutionalisation and the shift to models of community care, mental health practice has become increasingly focused on managing the risks posed by service users. However, the effects of risk management on workers’ professional identities have not been investigated empirically in Australia. Drawing on in-depth interviews with mental health workers from Victoria, Australia, this paper explores the diverse ways in which these workers adapted the formal technologies of risk management (e.g., the completion of risk assessment screens) to their professional identities. Some workers experienced risk management technologies as constraining their interventions with clients, while others saw these technologies as providing opportunities to strengthen and enhance their professional skills. Pondering these differences, the author speculates on the emergence of a new form of professional identity in the broader context of contemporary community mental health care.     

A GENOGRAM WITH AN ATTITUDE

The approach described in this paper is predicated on the fundamental belief that in order to become competent and ethical practitioners, students must understand themselves and how they see others. They must be given tools and skills that facilitate examinations of their own assumptions and beliefs about themselves, other, and how the world works. It is also essential that students examine how these assumptions and beliefs will influence the way they choose to conduct therapy. Once they are aware of their biases, they must learn to choose to consciously influence themselves in a way that permits their clients the largest room for change within the clients' own contexts of belief, understanding, experience, and possibility. In this paper I describe the use of the genogram as a tool to facilitate the process of gaining self knowledge. This tool has been used in a multicultural counseling course, as well as in professional development workshops for psychologists, mental health counselors, and marriage and family therapists.     

A FAMILY THERAPY INTERNSHIP IN A MULTIDISCIPLINARY HEALTHCARE SETTING: TRAINEES' AND SUPERVISOR'S REFLECTIONS

Family therapy doctoral students from American Association for Marriage and Family Therapy-accredited programs are required to complete a full-time clinical internship. The literature provides little information about these internship experiences. Two doctoral-level marriage and family therapists summarize their professional and personal experiences in their internships located within a multidisciplinary healthcare setting. In addition, their supervisor reports on her experiences working with marriage and family therapy doctoral interns. We hope that this case report will stimulate all interns and their supervisors to provide feedback to their internship sites and graduate programs about their clinical training and the extent to which the programs prepared them for their marriage and family therapy careers in the larger health and mental health community.     

Exploring Stigmatization and Stigma Management in Mental Health Court: Assessing Modified Labeling Theory in a New Context

Drawing on Link and colleagues' modified labeling theory, this article examines whether the stigma management strategies defendants anticipate using after mental health court exit are associated with their reported experiences during court. Using survey data from 34 mental health court graduates, we find that respondents generally perceive the mental health court as procedurally just, did not experience stigmatizing shame, and anticipate using the inclusionary coping strategy of education over the exclusionary strategies of secrecy and withdrawal. Moreover, findings reveal that the anticipated use of stigma management strategies is associated with mental health court experiences in that procedural justice is associated with inclusionary coping strategies, while stigmatizing shame is associated with exclusionary coping strategies. We conclude by encouraging researchers to further explore the role of stigmatization and shame in specialty court contexts and to continue investigating these defendant perceptions of these courts' process.     

New Public Management et professions dans l’État : au-delà des oppositions, quelles recompositions ?

More and more reforms in public administrations are being conducted that are based on the principles and instruments of “new public management”. They have set off protest and collective actions by several professional groups in various sectors (health, education, justice, social work, research…), whence questions about the future of professional groups in public services, in particular about their autonomy, which these reforms threaten. The opposition between this new public management and certain professional groups, is not the final explanation to draw from an analysis of this situation. Should these changes be seen as the decline of professional groups and of their autonomy, as a mutation of professional models, an overhaul of professionalism, etc.? These questions, which current events in France and Europe have raised, are a matter for ongoing sociological thought. They are approached empirically, from the field, using varied scales of analysis and research. Forms of tension between this new public management and professional groups are explored.     

Managerial audit and community mental health: a study of rationalising practices in Finnish psychiatric outpatient clinics

In many European welfare states the reform of mental health services has been accompanied by the implementation of new forms of governance, including the introduction of managerial audit systems. While such systems have been developed for ‘good causes’, such as quality assurance, financial management and monitoring staff performance, they may simultaneously produce diverse and contradictory effects on practice. The aim of this article is to examine the role of one managerial audit system, introduced in psychiatric outpatient clinics in central Finland, and assess its impact on practice. Reference is made to modernising mental health policy in the UK as that has producedsimilar practics outcomes. The research was an empirical study of practice using a mixed-method case study design involving documentary research and semi-structured interviews. Insights from Mitchell Dean's notion of governmentalisation of government were utilised in the analysis. It was found that, although the audit system primarily served administrative needs, it began to reshape practice by reinforcing certain modes of working and excluding others. The analysis of community mental health work in Finland, with similar trends in the UK, highlights the connection between documentation, resource allocation and managerial priorities that reinforce particular styles of practice. In community mental health services it would appear that the problems of professional practice have become the problems of administration.     

Building bridges: the interface between adult mental health and child protection

Bringing together two distinct professional systems such as adult mental health and child protection challenges our strategies for making effective working together/working in partnership arrangements. And yet failures to make these arrangements increase the risk for children who may be suffering or likely to suffer significant harm as an outcome of their parents'/carers' mental health problems. This paper offers an analysis of the challenges inherent in bringing these systems together at the assessment interface, and offers some insights into the contribution each system can make to an integrated assessment process for children and their families. Copyright © 1999 John Wiley & Sons, Ltd.     

“A lot of work needs to be done”—Service provider perspectives of mental health services available to Croatia- and Bosnia-born migrants

Research suggests that migrants have higher rates of mental health disorders but are less likely to access mental health services, which highlights both their vulnerability to mental illness and inequity in service provision. Despite being large and established culturally similar migrant cohorts in Australia, Croatians and Bosnians are invisible in mental health research. This qualitative study collected practice-based evidence from eight mental health service providers who have had direct professional contact with these communities, in order to understand how they engage with services, barriers to uptake and provide suggestions for service improvements. Thematic analysis was used to identify themes across interviews, which were then compared against Yang and Hwang's Migrant Mental Health Service Utilisation Model. The study identified unique factors specific to Croatia- and Bosnia-born migrants that impact how they engage with services, including mandated/prescribed services, religious resources, knowledge resources, referral pathways and procedures, and service provider competencies. This study will promote a better understanding of the limitations of the current mental health service offerings for Croatia- and Bosnia-born migrants, making it significant to practitioners, mental health organizations, policymakers and the general public.     

A case study in defining developmental costs for quality assurance in mental health center programs

Issues related to the state-of-the-art of ambulatory mental health care review as well as to the resources necessary for planning and operating a quality assurance program may be hampering development of such programs in community mental health centers nationwide. Faced with the problem of responsible and prudent program management, it has become increasingly difficult for CMHC directors to implement innovative, but unproven, and often unpriced programs which have the potential to draw scarce professional resources away from direct service delivery. Pressure to implement CMHC program requirements that are not ordinarily considered revenue-producing in nature, for example, consultation and education services and quality assurance activities, may further create anxiety for mental health program directors, especially during periods when they are ostensibly confronted with the need to maximize CMHC revenues. Before mental health professionals and administrators of mental health programs can be expected to introduce quality assurance programs, they need to have some idea how much the system costs. The figures reported from three North Carolina mental health centers may offer some indication of what other mental health centers might expect to spend in developing a quality assurance program. Salary expenses for multidisciplinary staff participation in quality assurance activities are presented.     

The use of mental health care,psychotropic drugs and social services by divorced people: does informal support matter?

This study compares the mental health care, psychotropic drugs and social service use of divorced people (re-partnered or single) with that of married people. This paper questions whether the availability of informal support facilitates or substitutes for formal care seeking. Data from the Divorce in Flanders survey of 2009–2010 are used. Logistic regression analyses are performed separately for women (N = 3450) and men (N = 3020). Greater use of mental health care, psychotropic drugs and social services by single divorced men is explained by their higher need for care, while divorced women (especially single divorced) more frequently contact a general practitioner (GP), a psychiatrist, or a psychologist, regardless of their mental health, socio-economic background and informal support. Women who have support from non-family members are more inclined to use social services and to contact a GP, while support from family members is only positively related to GP consultations. With regard to men, informal support from non-family members positively influences each type of formal care seeking. Our results suggest that non-family members (and only among women, family members as well) can provide help and advice about seeking professional mental health care and social services, but they do not have an influence on psychotropic drug use.     

Clinical supervision for psychiatric nurses

Supervision does not represent merely the acquisition of facts. It is an emotionally charged process that touches on therapists' affective problems, interpersonal conflicts, problems in being helped, and problems in helping (Ekstein). As such, it is a process similar to, but not the same as, psychotherapy. Supervision is necessary for continued professional growth, no matter how skilled the nurse may be. Other mental health disciplines have long accepted supervision as an essential component of professional work. A number of methods can be used to review the therapist's work, including case material discussion, conjoint interviewing, direct observation, and review of mechanical recordings. This can be done individually, in groups, or among peers. A supervisor can be a senior clinician from any of the mental health disciplines. The nurse should not be limited to receiving supervision only from other nurses. Periodic evaluations of the supervisory relationship as well as the therapist's skills are recommended. Supervision is a valuable tool that the nurse therapist should use fully to develop the professional self.     

Group therapists' countertransference reactions to multiple deaths from aids

Group therapists for those with HIV Related Diseases are becoming the “professional” survivors of this world-wide epidemic. From their experiences we may learn a great deal more about the effects of multiple deaths on mental health care professionals. As therapists they are constantly eliciting and listening to the fears, hopes, agonies and terrors of those with this disease. They become the bereaved. Witnesses to the deaths of many of their group members, they struggle with a wide range of emotional responses while at the same time assisting surviving group members in their struggle to live with these deaths. Mourning reactions and countertransference phenomena are in abundance as these therapists grapple with these group processes. This article identifies and examines these therapists' responses by focusing on clinical illustrations drawn from their bi-weekly supervision sessions.     

“I Want to Be Who I Am”: Narratives of Transgender Persons

Research has documented the difficulties that face persons identifying as transgender, and that research has been steadily increasing. However, the bridge between research findings and practice is often elusive, particularly for those counselors, therapists, and other mental health professionals already in their respective professional lives. This retrospective phenomenological study documented the lives of 16 persons identifying as transgender (11 transwomen, five transmen) as they narrated the difficulties they encountered beginning in childhood through transition in adult life. Eight persons identifying as transgender were younger than age 40 years and eight were older than age 40 years and brought different narratives about their childhood, teen, and adult years.     

Meeting the Needs of the Mentally Ill Homeless in Massachusetts-Based Emergency Shelters

A statewide survey (response rate = 79.5%) of the emergency shelters designed for homeless individuals was conducted in Massachusetts to determine the prevalence of serious mental illness among residents and extent to which they received psychiatric services. An average prevalence rate of 22%, ranging from 1% to 70%, was reported despite the fact that 87% of the shelters restricted admission of those exhibiting severe behavioral problems. Nearly three-quarters of the shelters reported providing some mental health services as part of their program, and 80% had established ties with professional mental health agencies. Linkages with these mental health agencies greatly enhanced placement options for mentally ill persons. When queried on the most pressing community-based service needed for the homeless mentally ill, nearly two-thirds of the shelters reported a need for additional housing alternatives.     

The Marital/Family Therapist as an Expert Witness: Some Thoughts and Suggestions

The role of the therapist in forensic activities is highlighted from the standpoint of protection of the therapist from unauthorized disclosure to orientation and effectiveness in court in a step-by-step process. Conclusions reached that the adversary process and the role of mental health professional challenge the objectivity needed by the mental health professional.     

Managed care. The effect of case management on state psychiatric clients.

This study examined whether case management services, mandated under the managed care contract for adult clients in a medium-sized state psychiatric hospital in Tennessee between July 1996 and June 1997, were offered as specified, and the impact these services had on recidivism for individuals who were identified as having a severe or persistent mental illness. Although all of the clients were offered case management, 47% refused the service. Of the 14 who had one or more readmissions, six (43%) had case management. These findings demonstrate that health care providers must offer sufficient information to their clients so that they can use the managed care system more effectively.     

Are case management services associated with increased utilization of adolescent mental health treatment?

Retention in treatment is one of the strongest predictors of positive mental health outcomes. Adolescents, however, are particularly challenging to retain in mental health treatment. Concurrent case management services may offer one strategy for retaining youth in mental health treatment as it aims to reduce barriers to services, coordinate multiple services, and establish a consistent relationship between each client and a single contact person. This study combines three extant data sources from the state of Kansas to examine whether youths' participation in case management is associated with increased utilization of individual and group mental health treatment, controlling for client satisfaction, severity of mental health symptoms, and demographic factors. Linear regression results indicate that participation in case management services predicts increased utilization of both individual and group mental health treatment. Case management may be a useful tool for retaining adolescent clients in mental health services. Practical implications for community mental health service delivery are discussed.