Post-traumatic growth in psychosis: a systematic review and narrative synthesis.

BACKGROUND AND OBJECTIVE: People with psychosis report experiences of highly traumatic events. Positive change or post-traumatic growth (PTG) can occur as a result of traumatic experiences. Yet there is limited attention on PTG in psychosis, possibly due to the negative impact of psychotic symptoms on functioning and quality of life. The aim of this review was to identify significant correlates and mediators of PTG in psychosis, and to develop a conceptual framework synthesising facilitators of PTG in psychosis. METHOD: Ten electronic databases were searched in seven languages, and five journals and grey literature were searched in English. Quantitative studies were eligible if examining correlates, mediators, or the temporal relationship between PTG and one or more variables. Qualitative studies were eligible if describing PTG arising from experiences of psychosis. Findings from quantitative papers were grouped by analysis method, with significant correlates, mediators, and temporal relationships descriptively reported upon. Narrative synthesis was conducted on findings in qualitative papers. RESULTS: Thirty-seven papers were included. Significant correlates and mediators of PTG were identified. Mediators of PTG in psychosis included meaning in life, coping self-efficacy, core beliefs, and self-reported recovery. No studies describing the temporal relationship between PTG and psychosis were identified. The narrative synthesis identified seven facilitators of PTG in psychosis: Personal identity and strength, Receiving support, Opportunities and possibilities, Strategies for coping, Perspective shift, Emotional experience, and Relationships, giving the acronym PROSPER. CONCLUSIONS: Individuals with psychosis can be supported to grow from traumatic experiences. Clinicians can support PTG through the provision of trauma-informed care that supports positively valued identity changes. For researchers, the findings provide an evidence-based theoretical framework for conceptualising PTG, which can be validated through longitudinal cohort studies and underpin the development of new clinical interventions.

Social connectedness in adults with mental disorders: ecological validation of a conceptual framework for novel complex interventions.

BACKGROUND: Social connectedness interventions may improve the clinical outcomes and personal recovery of adults with mental disorders but many interventions lack a clear theory-base and show limited effectiveness. AIM: To evaluate the validity of a newly developed conceptual framework (the CIVIC framework: Closeness, Identity, Valued relationships, Involvement and Cared for and accepted) to function as the theory-base for novel social connectedness-based mental health interventions. METHOD: Semi-structured interviews with adults with diagnostically heterogeneous mental disorders (n = 13) and mental health professionals (n = 9). Participants reported their social connectedness experiences, their views on the CIVIC framework and potential targets for new interventions. Sequential inductive and deductive thematic analyses were used. Data quality was assessed through respondent validation. RESULTS: Both inductive and deductive analyses provided validation of the CIVIC framework. Additional themes of Stigma and Connectedness beyond social relationships were identified in the inductive analysis. Candidate interventions to target each CIVIC domain were identified. CONCLUSIONS: The CIVIC framework demonstrates ecological validity and can therefore serve as the theory-base for the development of novel social connectedness-based interventions. This study indicates that interventions would be most effective when they incorporate evidence-based approaches which target each of the categories described by the CIVIC framework.

The mechanisms and processes of connection: developing a causal chain model capturing impacts of receiving recorded mental health recovery narratives.

BACKGROUND: Mental health recovery narratives are a core component of recovery-oriented interventions such as peer support and anti-stigma campaigns. A substantial number of recorded recovery narratives are now publicly available online in different modalities and in published books. Whilst the benefits of telling one's story have been investigated, much less is known about how recorded narratives of differing modalities impact on recipients. A previous qualitative study identified connection to the narrator and/or to events in the narrative to be a core mechanism of change. The factors that influence how individuals connect with a recorded narrative are unknown. The aim of the current study was to characterise the immediate effects of receiving recovery narratives presented in a range of modalities (text, video and audio), by establishing the mechanisms of connection and the processes by which connection leads to outcomes. METHOD: A study involving 40 mental health service users in England was conducted. Participants were presented with up to 10 randomly-selected recovery narratives and were interviewed on the immediate impact of each narrative. Thematic analysis was used to identify the mechanisms of connection and how connection leads to outcome. RESULTS: Receiving a recovery narrative led participants to reflect upon their own experiences or those of others, which then led to connection through three mechanisms: comparing oneself with the narrative and narrator; learning about other's experiences; and experiencing empathy. These mechanisms led to outcomes through three processes: the identification of change (through attending to narrative structure); the interpretation of change (through attending to narrative content); and the internalisation of interpretations. CONCLUSIONS: This is the first study to identify mechanisms and processes of connection with recorded recovery narratives. The empirically-based causal chain model developed in this study describes the immediate effects on recipients. This model can inform selection of narratives for use in interventions, and be used to support peer support workers in recounting their own recovery narratives in ways which are maximally beneficial to others.

Long-stay in forensic-psychiatric care in the UK.

PURPOSE: Forensic services provide care for mentally disordered offenders. In England this is provided at three levels of security-low, medium and high. Significant number of patients within these settings remain detained for protracted periods of time. This is both very costly and restrictive for individuals. No national studies have been conducted on this subject in England. METHODS: We employed a cross-sectional design using anonymised data from medical records departments in English secure forensic units. Data were collected from a large sample of medium secure patients (n = 1572) as well as the total high secure patient population (n = 715) resident on the census date (01-04-2013). We defined long-stay as a stay of more than 10 years in high, 5 years in medium or 15 years in a mix of high and medium secure settings. Long-stay status was assessed against patient demographic and admission information. RESULTS: We identified a significant proportion of long-stayers: 23.5% in high secure and 18.1% in medium secure care. Amongst medium secure units a large variation in long-stay prevalence was observed from 0 to 50%. Results indicated that MHA section, admission source and current ward type were independent factors associated with long-stay status. CONCLUSION: This study identified a significant proportion of long-stayers in forensic settings in England. Sociodemographic factors identified in studies in individual settings may be less important than previously thought. The large variation in prevalence of long-stayers observed in the medium secure sample warrants further investigation.

Unregistered health care staff's perceptions of 12 hour shifts: an interview study.

AIM: The purpose of the study was to explore unregistered health care staff's perceptions of 12 hour shifts on work performance and patient care. BACKGROUND: Many unregistered health care staff work 12 hour shifts, but it is unclear whether these are compatible with good quality care or work performance. METHOD: Twenty five health care assistants from a range of care settings with experience of working 12 hour shifts took part in interviews or focus groups. RESULTS: A wide range of views emerged on the perceived impact of 12 hour shifts in different settings. Negative outcomes were perceived to occur when 12 hour shifts were combined with short-staffing, consecutive long shifts, high work demands, insufficient breaks and working with unfamiliar colleagues. Positive outcomes were perceived to be more likely in a context of control over shift patterns, sufficient staffing levels, and a supportive team climate. CONCLUSION: The perceived relationship between 12 hour shifts and patient care and work performance varies by patient context and wider workplace factors, but largely focuses on the ability to deliver relational aspects of care. IMPLICATIONS FOR NURSING MANAGEMENT: Nursing managers need to consider the role of other workplace factors, such as shift patterns and breaks, when implementing 12 hour shifts with unregistered health care staff.

Systematic review and citation content analysis of the CHIME framework for mental health recovery processes: recommendations for developing influential conceptual frameworks.

Objectives: To identify design features of the CHIME conceptual framework of mental health recovery which are associated with high rates of citation. Research Design and Methods: Systematic review of all citations of the Connectedness, Hope, Identity, Meaning, and Empowerment (CHIME) framework of mental health recovery. Papers citing CHIME were screened and extracted from three citation databases. Citation content analysis was used to investigate associations between nine CHIME design features. Citations were investigated across six forms of visibility: all citations; Anglophone vs non-Anglophone; academic vs non-academic; academic discipline; professional group; and clinical population. Results: There were 915 eligible documents identified. Six CHIME framework design features met predefined thresholds for high levels of influence: (i) using a systematic review methodology for development, (ii) adopting a memorable acronym, (iii) having disaggregable components, and being unaligned to a (iv) particular discipline (i.e., transdisciplinary), (v) professional group, or (vi) diagnostic population. Documents from Anglophone countries were more likely to cite CHIME with reference to trans-professional (χ2=3.96, df=1, p=0.05) and ethnicity sub-group analysis (p=0.039) design features than non-Anglophone documents. Non-academic documents were more likely to cite the acronym design feature than academic papers (χ2=5.73, df=1, p=0.01). Public Health-related publications were more likely to cite CHIME within a trans-diagnostic framework (χ2=16.39, df=1, p<0.001) than other disciplines. Conclusions: The influence and impact of conceptual frameworks for recovery are increased when the framework is underpinned by a systematic review, includes disaggregable components which can be summarized using a memorable acronym, and when the framework is transdisciplinary, trans-professional, and trans-diagnostic.

Typology of content warnings and trigger warnings: Systematic review.

Content and trigger warnings give information about the content of material prior to receiving it. Different typologies of content warnings have emerged across multiple sectors, including health, social media, education and entertainment. Benefits arising from their use are contested, with recent empirical evidence from educational sectors suggesting they may raise anxiety and reinforce the centrality of trauma experience to identity, whilst benefits relate to increased individual agency in making informed decisions about engaging with content. Research is hampered by the absence of a shared inter-sectoral typology of warnings. The aims of this systematic review are to develop a typology of content warnings and to identify the contexts in which content warnings are used. The review was pre-registered (ID: CRD42020197687, URL: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020197687) and used five sources: electronic databases covering multiple sectors (n = 19); table of contents from multi-sectoral journals (n = 5), traditional and social media websites (n = 53 spanning 36 countries); forward and backward citation tracking; and expert consultation (n = 15). In total, 6,254 documents were reviewed for eligibility and 136 documents from 32 countries were included. These were synthesised to develop the Narrative Experiences Online (NEON) content warning typology, which comprises 14 domains: Violence, Sex, Stigma, Disturbing content, Language, Risky behaviours, Mental health, Death, Parental guidance, Crime, Abuse, Socio-political, Flashing lights and Objects. Ten sectors were identified: Education, Audio-visual industries, Games and Apps, Media studies, Social sciences, Comic books, Social media, Music, Mental health, and Science and Technology. Presentation formats (n = 15) comprised: education materials, film, games, websites, television, books, social media, verbally, print media, apps, radio, music, research, DVD/video and policy document. The NEON content warning typology provides a framework for consistent warning use and specification of key contextual information (sector, presentation format, target audience) in future content warning research, allowing personalisation of content warnings and investigation of global sociopolitical trends over time.

Recorded Mental Health Recovery Narratives as a Resource for People Affected by Mental Health Problems: Development of the Narrative Experiences Online (NEON) Intervention.

BACKGROUND: The internet enables sharing of narratives about health concerns on a substantial scale, and some digital health narratives have been integrated into digital health interventions. Narratives describing recovery from health problems are a focus of research, including those presented in recorded (eg, invariant) form. No clinical trial has been conducted on a web-based intervention providing access to a collection of Recorded Recovery Narratives (RRNs). OBJECTIVE: This study presents knowledge produced through the development of the Narrative Experiences Online (NEON) Intervention, a web-based intervention incorporating the algorithmic recommendation of RRNs. METHODS: Knowledge was gathered through knowledge integration (KI) activities. KI1 synthesized previous studies to produce the NEON Impact Model describing how accessing RRNs produces health-related outcomes. KI2 developed curation principles for the NEON Collection of RRNs through consultation with the NEON Lived Experience Advisory Panel and the curation of a preliminary collection. KI3 identified harm minimization strategies for the NEON Intervention through consultation with the NEON International Advisory Board and Lived Experience Advisory Panel. The NEON Intervention was finalized through 2 research studies (RS). In RS1, mental health service users (N=40) rated the immediate impact of randomly presented narratives to validate narrative feedback questions used to inform the recommendation algorithm. In RS2, mental health service users (n=25) were interviewed about their immediate response to a prototype of the NEON Intervention and trial procedures and then were interviewed again after 1 month of use. The usability and acceptability of the prototype and trial procedures were evaluated and refinements were made. RESULTS: KI1 produced the NEON Impact Model, which identifies moderators (recipient and context), mechanisms of connection (reflection, comparison, learning, and empathy), processes (identification of change from narrative structure or content and internalization of observed change), and outcomes (helpful and unhelpful). KI2 identified 22 curation principles, including a mission to build a large, heterogeneous collection to maximize opportunities for connection. KI3 identified seven harm minimization strategies, including content warnings, proactive and reactive blocking of narratives, and providing resources for the self-management of emotional distress. RS1 found variation in the impact of narratives on different participants, indicating that participant-level feedback on individual narratives is needed to inform a recommender system. The order of presentation did not predict narrative feedback. RS2 identified amendments to web-based trial procedures and the NEON Intervention. Participants accessed some narratives multiple times, use reduced over the 4-week period, and narrative feedback was provided for 31.8% (105/330) of narrative accesses. CONCLUSIONS: RRNs can be integrated into web-based interventions. Evaluating the NEON Intervention in a clinical trial is feasible. The mixed methods design for developing the NEON Intervention can guide its extension to other clinical populations, the design of other web-based mental health interventions, and the development of narrative-based interventions in mental health.

The VOICES Typology of Curatorial Decisions in Narrative Collections of the Lived Experiences of Mental Health Service Use, Recovery, or Madness: Qualitative Study.

BACKGROUND: Collections of lived experience narratives are increasingly used in health research and medical practice. However, there is limited research with respect to the decision-making processes involved in curating narrative collections and the work that curators do as they build and publish collections. OBJECTIVE: This study aims to develop a typology of curatorial decisions involved in curating narrative collections presenting lived experiences of mental health service use, recovery, or madness and to document approaches selected by curators in relation to identified curatorial decisions. METHODS: A preliminary typology was developed by synthesizing the results of a systematic review with insights gained through an iterative consultation with an experienced curator of multiple recovery narrative collections. The preliminary typology informed the topic guide for semistructured interviews with a maximum variation sample of 30 curators from 7 different countries. All participants had the experience of curating narrative collections of the lived experiences of mental health service use, recovery, or madness. A multidisciplinary team conducted thematic analysis through constant comparison. RESULTS: The final typology identified 6 themes, collectively referred to as VOICES, which stands for values and motivations, organization, inclusion and exclusion, control and collaboration, ethics and legal, and safety and well-being. A total of 26 subthemes related to curation decisions were identified. CONCLUSIONS: The VOICES typology identifies the key decisions to consider when curating narrative collections about the lived experiences of mental health service use, recovery, or madness. It might be used as a theoretical basis for a good practice resource to support curators in their efforts to balance the challenges and sometimes conflicting imperatives involved in collecting, organizing, and sharing narratives. Future research might seek to document the use of such a tool by curators and hence examine how best to use VOICES to support decision making.

INCRESE: Development of an Inventory to Characterize Recorded Mental Health Recovery Narratives.

OBJECTIVE: Mental health recovery narratives are increasingly used in clinical practice, public health campaigns, and as directly-accessed online resources. No instrument exists to describe characteristics of individual recovery narratives. The aims were to develop and evaluate an inventory to characterize recorded recovery narratives. RESEARCH DESIGN AND METHODS: A preliminary version of the Inventory of Characteristics of Recovery Stories (INCRESE) was generated from an existing theory-base. Feasibility and acceptability were evaluated by two coders each rating 30 purposively-selected narratives. A refined version was produced and a formal evaluation conducted. Reliability was assessed by four coders each rating 95 purposively-selected narratives. Inter-coder reliability was assessed using Fleiss's kappa coefficients; test-retest reliability was assessed using intra-class correlation coefficients (ICCs). RESULTS: Multiple refinements to description, coding categories, and language were made. Data completeness was high, and no floor or ceiling effects were found. Intercoder reliability ranged from moderate (k=0.58) to perfect (k=1.00) agreement. Test-retest reliability ranged from moderate (ICC=0.57) to complete (ICC=1.00) agreement. The final INCRESE comprises 77 items spanning five sections: Narrative Eligibility; Narrative Mode; Narrator Characteristics; Narrative Characteristics; Narrative Content. CONCLUSION: INCRESE is the first evaluated tool to characterize mental health recovery narratives. It addresses current concerns around normative recovery narratives being used to promote compulsory wellness, e.g. by identifying narratives that reject diagnosis as an explanatory model and those with non-upward trajectories. INCRESE can be used to establish the diversity of a narrative collection and will be used in the NEON trials (ISRCTN11152837, ISRCTN63197153, ISRCTN76355273) to allow a recommender system to match narratives to participants.

Conceptual framework for social connectedness in mental disorders: Systematic review and narrative synthesis.

BACKGROUND: Adults with mental disorders are at a high risk of loneliness. Loneliness has been implicated in a wide variety of physical and mental health problems. Social connectedness interventions are one means to tackle loneliness but have shown mixed effectiveness. This study aims to: (1) identify existing measures of social connectedness and (2) develop a conceptual framework of social connectedness to inform future measurement and the development of new interventions. METHODS: A systematic review of studies from six bibliographic databases was conducted. Studies were included if a quantitative measure of social connectedness was used amongst samples of adults with a mental disorder. Two analyses were conducted: a best evidence synthesis of measurement properties for identified measures and a narrative synthesis of items from these measures. RESULTS: Twenty-eight papers were included, employing 21 different measures. Measurement properties were of poor or unknown quality. Data synthesis identified a five-dimension conceptual framework of social connectedness: Closeness, Identity and common bond, Valued relationships, Involvement and Cared for and accepted (giving the acronym CIVIC). LIMITATIONS: The majority of studies were conducted in high-income countries. It was not possible to validate the conceptual framework using the identified psychometric data. CONCLUSIONS: The new five-dimension framework of social connectedness in mental disorders provides the theoretical foundation for developing new measures and interventions for social connectedness.