A systematic review of policy and clinical guidelines on positive risk management.

BACKGROUND: National policies and guidelines advocate that mental health practitioners employ positive risk management in clinical practice. However, there is currently a lack of clear guidance and definitions around this technique. Policy reviews can clarify complex issues by qualitatively synthesising common themes in the literature. AIMS: To review and thematically analyse national policy and guidelines on positive risk management to understand how it is conceptualised and defined. METHOD: The authors completed a systematic review (PROSPERO: CRD42019122322) of grey literature databases (NICE, NHS England, UK Government) to identify policies and guidelines published between 1980 and April 2019. They analysed the results using thematic analysis. RESULTS: The authors screened 4999 documents, identifying 7 eligible policies and 19 guidelines. Qualitative synthesis resulted in three main themes: i) the conflicting aims of positive risk management; ii) conditional positive risk management; and iii) responsible positive risk management. CONCLUSIONS: Analysis highlighted discrepancies and tensions in the conceptualisation of positive risk management both within and between policies. Documents described positive risk management in different and contradictory terms, making it challenging to identify what it is, when it should be employed, and by whom. Five policies offered only very limited definitions of positive risk management.

Minimal use of ICD social determinant or phenomenological codes in mental health care records.

BACKGROUND: We have previously argued that psychiatric diagnosis, by focusing on pathology, minimises the role of psychosocial factors. Despite suggestions that traditional diagnosis is the only way to access treatment services, we have recommended standardised use of existing codes for possible social determinants and precise description of psychological phenomena. AIMS: This study examines the current use of social determinant and phenomenological codes in mental health care records. METHODS: Data provided by a local NHS Trust included 21,701 cases with a first contact date between 01 January 2015 and 01 January 2016, 4656 of whom received a primary diagnosis. RESULTS: Overall, codes for possible social determinants were used on only 43 occasions, for 39 individuals (0.8% of the 4656 people receiving a primary diagnosis). Comparison with relevant baseline frequencies revealed a highly significant under-reporting of key social determinants. 19 cases (0.4% of 4.656) used codes for precise description of specific psychological phenomena. CONCLUSIONS: Available ICD codes for social determinants and specific psychological phenomena are under-used in clinical practice.

Positive risk management: Staff perspectives in acute mental health inpatient settings.

AIMS: To explore inpatient staff's understanding and implementation of positive risk management. BACKGROUND: Risk management is an essential skill for staff working in acute mental health inpatient settings. National policies advocate the use of positive risk management as a form of collaborative, recovery-focused risk management. However, little is known about how staff understand, operationalize, and use positive risk management in practice. DESIGN: Qualitative reflexive thematic analysis study. METHODS: The authors recruited a purposive sample of healthcare professionals working in acute inpatient settings (N = 16) in 2019 across three National Health Service Trusts in the North-West of England. Participants completed semi-structured interviews which were analysed using reflexive thematic analysis. RESULTS: The analysis generated three themes: (a) within staff barriers; (b) within service user barriers; and (c) delivery in practice. CONCLUSION: Understanding and implementation of positive risk management was dependant on multiple factors, including staffs' beliefs about mental health, levels of worry and anxiety, and amount of experience and seniority. Staff were more likely to use positive risk management with service users that they perceived as being trustworthy and less risky. Use of positive risk management was reliant on the support practitioners received, how able they were to view situations from multiple perspectives, and the degree to which they felt able to prioritize positive risk management. IMPACT: Although staff expressed the desire and intention to practice positive risk management, the current study highlights challenges around operationalization and implementation. The authors discuss the clinical implications of the findings.

How did mental health become so biomedical? The progressive erosion of social determinants in historical psychiatric admission registers.

This paper explores the historical developments of admission registers of psychiatric asylums and hospitals in England and Wales between 1845 and 1950, with illustrative examples (principally from the archives of the Rainhill Asylum, UK). Standardized admission registers have been mandatory elements of the mental health legislative framework since 1845, and procedural changes illustrate the development from what, today, we would characterize as a predominantly psychosocial understanding of mental health problems towards primarily biomedical explanations. Over time, emphasis shifts from the social determinants of admission to an asylum to the diagnosis of an illness requiring treatment in hospital. We discuss the implications of this progressive historical diminution of the social determinants of mental health for current debates in mental health care.

What is the relationship between post-traumatic stress disorder, extreme appraisals of internal state and symptoms in bipolar disorder?

BACKGROUND: It is important to understand the factors associated with more severe mood symptoms in bipolar disorder. The integrative cognitive model of bipolar disorder proposes that extreme appraisals of changes to internal states maintain and exacerbate mood symptoms. AIMS: The current study aimed to investigate if post-traumatic stress disorder (PTSD) is related to current depressive and manic bipolar symptoms, and whether this relationship is mediated by appraisals of internal state. METHOD: Participants with bipolar disorder (n = 82) from a randomized controlled trial of cognitive therapy for bipolar disorder (the TEAMS trial) completed self-reported questionnaires assessing appraisals of internal state, generalized anxiety symptoms, and self-reported and observer-rated depressive and manic symptoms. Clinical interviews assessed PTSD co-morbidity. RESULTS: Participants with bipolar and co-morbid PTSD (n = 27) had higher depressive symptoms and more conflicting appraisals than those without PTSD. Regression analyses found PTSD to be associated with depressive symptoms but not manic symptoms. Conflicting appraisals were found to be associated only with manic symptoms meaning that the planned mediation analysis could not be completed. CONCLUSIONS: Findings provide partial support for the integrative cognitive model of bipolar disorder and highlight the need for transdiagnostic treatments in bipolar disorder due to the prevalence and impact of trauma and co-morbidity. Working on trauma experiences in therapy may impact on depressive symptoms for those with bipolar disorder and co-morbid PTSD.

Feasibility and Patient Experiences of Method of Levels Therapy in an Acute Mental Health Inpatient Setting.

This study sought to investigate the feasibility and acceptability of a flexible psychotherapeutic approach - the Method of Levels (MOL) - in an acute mental health inpatient setting. A multi methods approach was used. The feasibility of implementation was investigated by examining the referral rate and the attendance patterns of participants. The acceptability of MOL was explored using a thematic analysis of participant interviews and by recording attendance patterns of participants. Inpatient staff consistently referred patients and the majority of eligible people accepted invitations for therapy. Thematic analysis of peoples' experiences of the therapy generated themes that described participants' experiences of MOL in contrast to routine NHS care, having spent meaningful time with the therapist, and having gained something from the session. The referral rate and uptake of MOL therapy indicates that the resource was appropriate for the setting and acceptable to most participants. Qualitative analyses indicated that participants were comfortable with the therapists' approach, felt understood, and there was a meaningful quality to their interaction. Participants also valued the opportunity to reflect and generate new perspectives of their difficulties. Further research is required to determine the effectiveness of the approach and its translational value beyond this pilot investigation.

Sources of Distress in First-Episode Psychosis: A Systematic Review and Qualitative Metasynthesis.

In this study, we aim to increase our understanding of the self-reported sources of distress among people who have experienced first-episode psychosis. Following a systematic literature search, 33 relevant studies containing first-person accounts of first-episode psychosis were identified, which were synthesized using thematic analysis. Two interrelated superordinate themes were identified: intrapersonal distress and interpersonal distress. Participants reported multiple, diverse, and multifaceted sources of distress across both themes. These were substantially different from those routinely recognized and targeted in clinical practice. This review suggests that practitioners who maintain a stance of genuine curiosity about the potential sources of distress for this population will be perceived as more helpful. The findings also highlight the importance of being service user-led when planning and delivering mental health care. Additional clinical and research implications are discussed.

Method of levels therapy for first-episode psychosis: The feasibility randomized controlled Next Level trial.

OBJECTIVE: We aimed to determine the feasibility and acceptability of Method of Levels (MOL) for people experiencing first-episode psychosis (FEP) to inform decision making about the therapy's suitability for further testing in a larger clinical trial. METHOD: A parallel group randomized controlled trial design was used. Participants (N = 36) were allocated to receive either treatment as usual (TAU) or TAU plus MOL. Recruitment and retention in the trial and the acceptability of the MOL intervention were the primary outcomes. RESULTS: The recruitment target was met within the planned time frame. Retention in the trial at final follow-up was 97%, substantially higher than the 80% threshold prespecified as a successful feasibility outcome. Participant feedback provided initial evidence of the acceptability of the study design and intervention for this population. CONCLUSION: Results support progressing to a larger trial of MOL for FEP. Recommendations for the design of future trials are provided.

Living the life you want following a diagnosis of bipolar disorder: A grounded theory approach.

Bipolar disorder (BD) is considered a severe and lifelong mental health diagnosis. However, there is growing evidence of people defying the odds and recovering. Processes underlying recovery remain poorly understood. This study aimed to explore these recovery processes and extend on the length of recovery defined within previous research. Twelve people previously diagnosed with BD, who had not experienced an episode of depression and/or mania for four or more years, were interviewed. Standardised diagnostic interviews (Structured Clinical Interview for Diagnostic and Statistical Manual-V, Research version) confirmed past diagnosis and recovery time. Qualitative methodology via grounded theory was used to analyse these personal accounts. The analysis revealed 10 overarching categories of what participants reported to be important in their recovery: support, recognition of the problem, believing that things can change and not giving up, instinctive curiosity, medication, psychological therapy, becoming the director of your own life, changing how I think, accepting who I am and how I feel, and looking after me. A model was developed to represent how categories were related. The study was limited by recruitment not leading to the inclusion of people who had distanced themselves from the label of BD. Potential transdiagnostic recovery processes also require further direct exploration. Critically, the study highlights that following a diagnosis of BD, people do experience long-term recovery achieved through self-determined pathways and that being able to live the life you want is therefore achievable. This challenges current diagnostic perspectives and societal messages of lifelong conditions.

Why I eat at night: A qualitative exploration of the development, maintenance and consequences of Night Eating Syndrome.

Night Eating Syndrome (NES), as a diagnosis, presents as a combination of disordered eating, sleep and mood. Patients identified as having both NES and obesity demonstrate poorer outcomes in terms of weight loss compared to those with NES only. However, research focusing on psychological factors associated with NES remains relatively underdeveloped. This study aimed to explore the relationship between NES and the experience of emotion from the perspective of patients accessing a weight management service. Ten adults who met diagnostic criteria for moderate or full NES took part in a semi-structured interview. Data were analysed using a constructivist approach to grounded theory. A core concept to emerge from the analysis was termed 'emotional hunger'; reflecting an urge or need to satiate a set of underlying unmet emotional needs. It was underpinned by the following interrelated themes: (1) Cultivating a dependency on food; (2) Relying on food to regulate emotions; (3) Understanding the significance of night-time; (4) Acknowledging the consequences of night eating. This study provides an in-depth understanding of the relationship between NES and the experience of emotion from the perspective of patients attending a weight management service. Results have potential to inform future service development, particularly around the adoption of a more holistic approach to night eating behaviours.

Manage Your Life Online: A Web-Based Randomized Controlled Trial Evaluating the Effectiveness of a Problem-Solving Intervention in a Student Sample.

BACKGROUND: Evidence for the efficacy of computer-based psychological interventions is growing. A number of such interventions have been found to be effective, especially for mild to moderate cases. They largely rely on psychoeducation and 'homework tasks', and are specific to certain diagnoses (e.g. depression). AIMS: This paper presents the results of a web-based randomized controlled trial of Manage Your Life Online (MYLO), a program that uses artificial intelligence to engage the participant in a conversation across any problem topic. METHOD: Healthy volunteers (n = 213) completed a baseline questionnaire and were randomized to the MYLO program or to an active control condition where they used the program ELIZA, which emulates a Rogerian psychotherapist. Participants completed a single session before completing post-study and 2-week follow-up measures. RESULTS: Analyses were per protocol with intent to follow-up. Both programs were associated with improvements in problem distress, anxiety and depression post-intervention, and again 2 weeks later, but MYLO was not found to be more effective than ELIZA. MYLO was rated as significantly more helpful than ELIZA, but there was no main effect of intervention on problem resolution. CONCLUSIONS: Findings are consistent with those of a previous smaller, laboratory-based trial and provide support for the acceptability and effectiveness of MYLO delivered over the internet for a non-clinical sample. The lack of a no-treatment control condition means that the effect of spontaneous recovery cannot be ruled out.

What is good communication for people living with dementia? A mixed-methods systematic review.

BACKGROUND: Many strategies have been recommended to support caregivers in communicating with people who live with dementia. However, less is known about what makes communication a good and meaningful experience from the perspective of people with dementia. Understanding this may enhance the person with dementia's sense of connectedness, strengthen their relationships, and facilitate person-centered care. The current review aimed to evaluate research that examined experiences of communication in people living with dementia. Studies that examined reports provided by people with dementia, healthcare professionals, and family caregivers were included. METHODS: A mixed-methods systematic review was conducted using PsychINFO, MEDLINE, and EMBASE databases. RESULTS: After applying the eligibility criteria, 15 studies were included. Although eight of these recruited people with dementia, only one focused on their perspectives of communication experiences and the remaining studies focused on the perspectives of family caregivers and healthcare professionals. These studies either explored experiences without suggestions of communication methods, "open exploration," or through examining experiences of strategies, "exploration of strategies." A significant theme was around communication difficulties that affected interpersonal relationships and activities of daily living. Conversely, personhood strategies and a strong underlying relationship were believed to facilitate communication. The one study that examined the perspectives of people with dementia emphasized the importance of retaining valued relationships and feeling respected during communication. CONCLUSIONS: The need to involve people with dementia in research, particularly around their experiences of communication, is evident. Such research would be imperative for facilitating person-centered care, strengthening social relationships, and informing training programs.

Personal Accounts of Discontinuing Neuroleptic Medication for Psychosis.

We conducted this study to explore personal accounts of making choices about taking medication prescribed for the treatment of psychosis (neuroleptics). There are costs and benefits associated with continuing and discontinuing neuroleptics. Service users frequently discontinue neuroleptics; therefore, we specifically considered these decisions. We used a grounded theory approach to analyze transcripts from interviews with 12 participants. We present a preliminary grounded theory of the processes involved in making choices about neuroleptic medication. We identified three tasks as important in mediating participants' choices: (a) forming a personal theory of the need for, and acceptability of taking, neuroleptic medication; (b) negotiating the challenges of forming alliances with others; and (c) weaving a safety net to safeguard well-being. Progress in the tasks reflected a developmental trajectory of becoming an expert over time and was influenced by systemic factors. Our findings highlight the importance of developing resources for staff to facilitate service user choice.

Client Perceptions of Helpfulness in Therapy: a Novel Video-Rating Methodology for Examining Process Variables at Brief Intervals During a Single Session.

BACKGROUND: The value of clients' reports of their experiences in therapy is widely recognized, yet quantitative methodology has rarely been used to measure clients' self-reported perceptions of what is helpful over a single session. AIMS: A video-rating method using was developed to gather data at brief intervals using process measures of client perceived experience and standardized measures of working alliance (Session Rating Scale; SRS). Data were collected over the course of a single video-recorded session of cognitive therapy (Method of Levels Therapy; Carey, 2006; Mansell et al., 2012). We examined the acceptability and feasibility of the methodology and tested the concurrent validity of the measure by utilizing theory-led constructs. METHOD: Eighteen therapy sessions were video-recorded and clients each rated a 20-minute session of therapy at two-minute intervals using repeated measures. A multi-level analysis was used to test for correlations between perceived levels of helpfulness and client process variables. RESULTS: The design proved to be feasible. Concurrent validity was borne out through high correlations between constructs. A multi-level regression examined the independent contributions of client process variables to client perceived helpfulness. Client perceived control (b = 0.39, 95% CI .05 to 0.73), the ability to talk freely (b = 0.30, SE = 0.11, 95% CI .09 to 0.51) and therapist approach (b = 0.31, SE = 0.14, 95% CI .04 to 0.57) predicted client-rated helpfulness. CONCLUSIONS: We identify a feasible and acceptable method for studying continuous measures of helpfulness and their psychological correlates during a single therapy session.

What are People's Experiences of a Novel Cognitive Behavioural Therapy for Bipolar Disorders? A Qualitative Investigation with Participants on the TEAMS Trial.

Background Psychological interventions for bipolar disorders typically produce mixed outcomes and modest effects. The need for a more effective intervention prompted the development of a new cognitive behavioural therapy, based on an integrative cognitive model ('Think Effectively About Mood Swings' [TEAMS] therapy). Unlike previous interventions, TEAMS addresses current symptoms and comorbidities, and helps clients achieve long-term goals. A pilot randomized controlled trial (the TEAMS trial) of the therapy has recently concluded. This study explored participants' experiences of TEAMS, recommendations for improvement and experiences of useful changes post-therapy. Methods Fourteen TEAMS therapy participants took part in semi-structured interviews. Their accounts were analysed using interpretative thematic analysis. Two researchers coded the dataset independently. Member checks were conducted of the preliminary themes. Results Two overarching themes; 'useful elements of therapy' and 'changes from therapy' encompassed 12 emerging subthemes. Participants appreciated having opportunities to talk and described the therapy as person-centred and delivered by caring, approachable and skilled therapists. Some recommended more sessions than the 16 provided. Helpful therapeutic techniques were reported to be, normalization about moods, methods to increase understanding of moods, relapse-prevention, reappraisal techniques and metaphors. However, some did not find therapeutic techniques helpful. Post-therapy, many reported changes in managing mood swings more effectively and in their thinking (although some participants reported changes in neither). Many described increased acceptance of themselves and of having bipolar disorder, increased productivity and reduced anxiety in social situations. Conclusions The present study evaluates participants' therapy experiences in detail, including aspects of therapy viewed as helpful, and meaningful post-therapy outcomes. Copyright © 2016 John Wiley & Sons, Ltd. KEY PRACTITIONER MESSAGE: This is the first paper to qualitatively explore people's experiences of individual psychotherapy for bipolar disorders. It highlights elements of psychotherapy described as particularly helpful or unhelpful and the clinical changes viewed as most impactful. Participants reported benefitting in a number of ways from TEAMS therapy. They valued learning to reappraise and problem-solve situations and manage moods. Participants identified TEAMS techniques as helpful, such as exploring advantages and disadvantages of moods, and building healthy self-states.

MindSurf: a pilot study to assess the usability and acceptability of a smartphone app designed to promote contentment, wellbeing, and goal achievement.

BACKGROUND: The Method of Levels (MOL) is a transdiagnostic cognitive therapy that promotes contentment, wellbeing, and goal achievement through the resolution of internal conflicts underlying psychological distress. MOL, based on Perceptual Control Theory (PCT), was developed in routine clinical practice and has been used effectively across different health services by different practitioners. Access to MOL-style questions through a smartphone app could, potentially, help both the general public maintain robust mental health, and also be a useful adjunct to therapy for clinical populations. The app is called MindSurf because of its focus on helping people explore their thinking. Prior to developing the app and using it with different populations it was necessary to determine whether such an idea would be usable for and acceptable to potential app users. Therefore, a pilot study was conducted with a non-clinical sample to assess the usability and acceptability of the app including monitoring whether the questions delivered in this way were associated with any adverse events. METHODS: A pilot study using quantitative as well as qualitative methods and incorporating a repeated measures, A-B design was conducted. RESULTS: The 23 participants were healthy adult volunteers who were all either undergraduate students, postgraduate students, or staff of the University of Manchester. They received MOL-style questions on their mobile phones over a 1-week period. Qualitative results were encouraging and indicated that the format and style of questioning were acceptable to participants and did not lead to increased worry or concern. A one-way, repeated measures ANOVA indicated that there was a nonsignificant decrease in scores on the 21-item Depression, Anxiety, and Stress Scale (DASS21) over a 2 week period. DISCUSSION: The results of the pilot study justified development of MindSurf and further testing once it is available for use. A power analysis indicated that the pilot study was underpowered to detect significant effects but provided important information regarding the appropriate sample size for future research. The pilot study also indicated that future research should investigate the effects of receiving more than three questions per day. CONCLUSION: Results of the pilot study indicate that MindSurf will be a usable and acceptable app. Its benefits should be further explored through longer studies with larger sample of both the general population as well as clinical populations.

Appraisals to affect: Testing the integrative cognitive model of bipolar disorder.

OBJECTIVE: Cognitive models have suggested that extreme appraisals of affective states and maladaptive affect regulation strategies are important in the development of bipolar symptomatology. Little is known about the pathway by which these appraisals and behaviours interact in the formation of activated and depressed affective states. This study tested the predictions that (1) ascent behaviours mediate the relationship between positive appraisals of activated mood and activation; and (2) descent behaviours mediate the relationship between negative appraisals of activated mood and depression. METHOD: A total of 52 individuals with a DSM-IV diagnosis of bipolar I or II disorder (confirmed by structured interview) completed biweekly assessments of affect regulation behaviours and mood for 4 weeks. Positive and negative appraisals of affective states were assessed at baseline through the Hypomanic Attitudes and Positive Prediction Inventory. Multilevel mediation analysis was used to explore the data. RESULTS: Ascent behaviours partially mediated the relationship between positive appraisals of activated mood and activation. Descent behaviours, but not negative appraisals of activated mood, predicted levels of depression indicating the absence of a mediation effect. CONCLUSION: The results suggest that positive appraisals of activated mood can escalate activation in individuals with bipolar disorder. Such appraisals may be inherently rewarding and reinforcing directly elevating levels of activation, whilst increasing individuals' use of ascent behaviours. The results are consistent with the view that appraisals and behaviours should be targeted during cognitive behavioural therapy for bipolar disorder. PRACTITIONER POINTS: It may be beneficial to target positive appraisals of activated mood in cognitive behavioural therapy for mania. Cognitive behavioural therapists may also wish to focus on identifying and targeting individuals' use of ascent behaviours to reduce highly activated states.

An Introduction to Using the Method of Levels (MOL) Therapy to Work with People Experiencing Psychosis.

This paper provides a basic introduction to using method of levels (MOL) therapy with people experiencing psychosis. As MOL is a direct application of perceptual control theory (PCT), a brief overview of the three main theoretical principles of this theory--control, conflict, and reorganization will be outlined in relation to understanding psychosis. In particular, how these principles form the basis of problem conceptualisation and determine what an MOL therapist is required to do during therapy will be illustrated. A practical description of MOL will be given, using case examples and short excerpts of therapeutic interactions. Some direct contrasts will also be made with cognitive behaviour therapy for psychosis (CBTp) and psychodynamic approaches (PA) in order to help illustrate the theory and practice of MOL.

Causal and mediating factors for anxiety, depression and well-being.

Background The relationship between well-being and mental ill health is complex; people may experience very low levels of well-being even in the absence of overt mental health problems. Aims This study tested the hypothesis that anxiety, depression and well-being have different causal determinants and psychological mediating mechanisms. Method The influence of causal and mediating factors on anxiety, depression and well-being were investigated in a cross-sectional online questionnaire survey hosted on a UK national broadcasting website. Results Multivariate conditional independence analysis of data from 27 397 participants revealed different association pathways for the two constructs. Anxiety and depression were associated with negative life events mediated by rumination; low levels of subjective well-being were associated with material deprivation and social isolation, mediated by adaptive coping style. Conclusions Our findings support the 'two continua' model of the relationship between psychological well-being and mental health problems, with implications for both treatment and prevention.

Using plain English and behaviourally specific language to increase the implementation of clinical guidelines for psychological treatments in schizophrenia.

BACKGROUND: Inequalities in the implementation of recommended psychological interventions for schizophrenia persist. Writing guidance in a particular style has been shown to improve service user intention to implement the recommendations. This current study explored this further in healthcare staff members. AIMS: Can behaviourally specific and plain English language improve healthcare intentions to perform actions in line with guidance for schizophrenia. METHOD: An independent measure, single blind, randomised control trial. Guidance was written and disseminated in two formats, the "original" and "alternative". Self-report measures were administered to assess the cognitive determents of behaviour as described by the Theory of Planned Behaviour, actual behaviour consistent with the guidance, comprehension and satisfaction with the guidance. RESULTS: No significant results were found when comparing the original guidance to the alternative for the cognitive determinants of behaviour, actual behaviour, comprehension or satisfaction. CONCLUSIONS: Behaviourally specific and plain English language does not affect healthcare professionals' intentions or behaviour to implement recommended guidance for the provision of psychological interventions for schizophrenia. A more multi-factorial approach including organisational culture may be required.