Still in the shadows: a national study of acute mental health unit location across New Zealand hospitals.

BACKGROUND: This study aimed to explore the location of acute mental health inpatient units in general hospitals by mapping their location relative to hospital facilities and community facilities and to compare their proximity to hospital facilities with that of general medical acute units. METHODS: We obtained Google maps and hospital site maps for all New Zealand public hospitals. Geographic data were analysed and mental health units' locations in relation to hospital facilities and public amenities were mapped. Radar plots were constructed comparing acute medical and mental health units' locations in relation to hospital facilities. RESULTS: Twenty-two mental health units were identified. They were located predominantly at the periphery of hospital campuses, but also at a distance from community facilities. Compared to acute medical units, mental health units were almost universally located further from shared hospital facilities - with distances approximately three times further to reach the main hospital entrance (2.7 times distance), the nearest public café (3.4 times), the emergency department (2.4 times), and medical imaging (3.3 times). CONCLUSION: Despite the reforms of the 20th Century, mental health units still appear to occupy a liminal space; neither fully integrated into the hospital, nor part of the community. The findings warrant further investigation to understand the impact of these structural factors on parity of health care provision between mental and physical health care and the ability of mental health care services to support recovery.

Relationship Between Clinicians' Inclination Toward Patients at Risk for Suicide (PRS) and Self-reported Countertransference.

OBJECTIVES: We investigate the relationship between clinicians' inclination toward treating patients at risk for suicide (PRS), and self-reported countertransference (CT). We consider these observed group differences to explore two competing interpretations for observed CT patterns from a primary study; whether CT patterns are more consistent with defensive attitudes or an adaptative CT montage. METHOD: We used one-way ANOVA, Tuckey post-hoc, and t-test, to compare clinicians (n = 267) grouped by self-ratings of positive, neutral or non-positive inclination toward working with PRS, with regard to their level of endorsement of the Therapist Response Questionnaire (TRQ) with PRS. We hypothesized that positively inclined clinicians would demonstrate greater CT literacy skills than other clinicians, reflected in lower endorsement of negative/hindering CT and higher endorsement of positive/facilitating CT to PRS. RESULTS: Compared to non-positively inclined clinicians, positively inclined clinicians endorsed significantly lower levels of two potentially negative/hindering CT dimensions, factor 1: entrapped/rejecting and, factor 5: protective/overinvolvement, and higher levels of the only positive/facilitating CT dimension, factor 2: fulfilled/engaging. Neutral clinicians reported similar CT patterns to positively inclined clinicians. CONCLUSIONS: Hypothesis of greater CT literacy from positively inclined clinicians appears supported. Observed differences in CT endorsement by inclination group tend to support the CT montage interpretation of our original findings more than the defense mechanism interpretation proposed. Similarities in CT patterns between positively inclined and neutral clinicians suggest that positive inclination to PRS, as assessed in this study, may not be countertransferential per se.

Gender and intersecting vulnerabilities on the mental health unit: Rethinking the dilemma.

Background: Gender is routinely pitched as a key determinant of vulnerability for staff and residents on acute mental health inpatient units. Since the 1960's mixed gender units have become more prominent in Western health systems, yet questions remain around the configuration of these units, including how to ensure emotional and physical safety of those living and working in them. Methods: This paper draws on a large study of the lived experiences of 42 staff and 43 service users from different acute mental health units in New Zealand. We conducted thematic analysis of interview data from four units with diverse architectural layouts to identify key themes central to decisions around gender and spatial design. Results: Key themes emerged around gender-related trauma histories, safety perceptions and vulnerabilities, accommodation of gender-diverse and non-binary mental health service users, and gender-specific needs and differences. A further theme, of it goes beyond gender emphasized that there are many other non-gender attributes that influence vulnerability on the unit. Conclusions: While findings emphasize the need for safe places for vulnerable people, trauma-informed care, access to staff who "understand," and recreation that is meaningful to the individual, we question if the dilemma of gender-separation vs. gender-mixing is an outmoded design consideration. Instead, we argue that a flexible, person-centered approach to provision of care, which values autonomy, privacy, and safety as defined by each service user, and that promotes choice-making, obviates a model where gender accommodations are fore. We found that a gender-exclusive narrative of vulnerability understates the role of other identifiers in dynamics of risk and vulnerability, including age, physicality, past violence, trauma history, mental unwellness, and substance use. We conclude gender need not be a central factor in decisions around design of prospective built unit environments or in occupational and clinical decisions. Instead, we suggest flexible spatial layouts that accommodate multiple vulnerabilities.

'My Work Matters': A Qualitative Exploration of Why Staff Love Working in Acute Mental Health.

Research findings and media coverage of staff experiences of working in mental health settings tend to focus on the negative aspects of the work such as burnout and stress. These negative aspects affect job satisfaction. Job satisfaction can be understood through the lense of Self-Determination theory, which emphasises the importance of autonomy, competence and relatedness (connection) in job satisfaction. This article reports on staff views on positive aspects of working in acute mental health care, drawing on qualitative interview data collected for a larger study of the social and architectural environment of mental health inpatient facilities in New Zealand. Forty-two inpatient mental health staff participated in semi-structured interviews about their experiences of working in such facilities, sharing the positive aspects of working in this setting, including 'what they liked most'. Responses were thematically analysed using the Framework Method to identify and organise key themes that were refined iteratively, checking for agreement between researchers. Four key themes were identified: work that matters; the people; the physical and social environment and the extrinsic rewards/personal benefits. The results provide an alternative framing of working in acute mental health settings compared, with commonly reported research findings and media coverage focusing on staff burnout and stress in these settings. Despite the much-documented challenges of working in this often poorly resourced and stigmatized area of health, most participants spoke warmly and enthusiastically about what they did, with frequent use of the word 'love' in relation to their work. This was largely because they found the work and social relationships rewarding and they were able to make an important contribution to the wellbeing of mental health service users.

The Role of Courtyards within Acute Mental Health Wards: Designing with Recovery in Mind.

The role of courtyards and other outdoor spaces in the recovery of acute mental healthcare users has been gaining international appreciation and recognition. However, the physical properties and conditions necessary for therapeutic and rehabilitative engagement remain to be clearly established. This paper contributes to that knowledge by triangulating evidence from the literature, exemplar case studies of good practice and first-hand accounts of the experiences of staff and service users from four acute mental health facilities. The findings are then aligned with a well-established recovery framework (CHIMES) in light of existing landscape architecture knowledge. Within the complexity of varied mental health environments, this work establishes landscape architectural design requirements and qualities essential for recovery. Rather than adopting a prescriptive quantitative approach setting out areas, numbers of elements, etc., the proposed framework recommends a performance-based model and the creation of a cohesive network of microspaces that mesh into a design of outdoor areas. In this way, design details, materials, vegetation and the variety of spaces can be modified to suit service user population demographics and site-specific needs.

Decoding the Psychiatric Space: Cross Country Comparison of Facilities for Mental Health Service Users.

Normalisation theory made perfect sense at the onset of de-institutionalisation. To map its influence on mental health facilities, research was conducted and began with ten facilities within England (UK) and France, followed by a further two in England and four in New Zealand. A checklist tailored to mental health facilities was used to measure the extent to which the facility looked domestic or institutional. Hence, the mental health checklist architecturally measured domesticity versus institutionalisation in psychiatric architecture. It consisted of 212 features, grouped into three main categories-context and site; building; and space and room-and was based on a pre-existing checklist designed for hostels for those with learning disabilities. The mental health checklist was developed and piloted in Europe and reflected European de-institutionalisation principles. Cross-country comparison revealed that patient acuity was potentially not a determinant of institutional buildings for mental health. Institutional facilities in France were detected, and some of the most domestic facilities were within England, with the most recent sample having a greater tendency towards the more institutional end. Those in New Zealand tended towards the most institutional. Across all 16 facilities, there were very few universal institutional and domestic features, raising the ambiguity of a clearly defined stereotype of facilities for mental health service users. Consequently, the current fluidity of design across and within countries provides a significant opportunity for designers and mental health providers to consider non-institutional design, particularly at the planning stage. The use of the mental health checklist facilitates this debate. Future research in other geographical areas and through further consideration of cultural differences provides further opportunities to extend research in this area, with the potential to enhance and improve the lived experience of users of mental health services.

Places of safety? Fear and violence in acute mental health facilities: A large qualitative study of staff and service user perspectives.

AIM: To understand violence on acute mental health units according to staff and service user perspectives and experiences. BACKGROUND: The collateral damage of violence in acute inpatient mental health settings is wide-ranging, impacting on the health and wellbeing of staff and service users, and detrimental to public perceptions of people who are mentally unwell. Despite international research on the topic, few studies have examined psychiatric unit violence from both staff and service user perspectives. METHODS: We conducted in-depth interviews with 85 people (42 staff, 43 service users) in four adult acute mental health inpatient units in New Zealand. We undertook a thematic analysis of perspectives on the contributing factors and consequences of violence on the unit. RESULTS: Both staff and service users indicated violence was a frequent problem in acute inpatient units. Four themes regarding the causes of violence emerged: individual service user factors, the built environment, organisational factors, and the overall social milieu of the unit. Staff often highlighted complexities of the system as causal factors. These included the difficulties of managing diverse service user illnesses within an inadequate and unsafe built environment whilst having to contend with staffing issues and idiosyncrasies relating to rule enforcement. In contrast, service users talked of their needs for care and autonomy not being met in an atmosphere of paternalism, boredom due to restrictions and lack of meaningful activities, enforced medication, and physical confinement as precipitants to violence. Two broader themes also emerged, both relating to empathy. Both staff and service users exhibited 'othering' (characterised by a profound lack of empathy) in relation to acutely unwell individuals. Explanations for violent behaviour on the unit differed between groups, with service users being more likely to attribute unwanted behaviour to contextual factors and staff more likely to 'blame' mental illness. The consequences of violence included stress, physical injury, and a culture of fear and stigma. CONCLUSION: Violence in acute inpatient mental health units in New Zealand is a significant, complex, and unresolved problem negatively impacting the therapeutic mission of these settings. Further in-depth qualitative investigations are urgently required into what is experienced as violence by service users, their view of how violence occurs, the role of fear and power relations, and the contributions of the built and organisational environment to all forms of violence to all unit users. A core function of the acute mental health unit is to offer a therapeutic environment for individuals at their most vulnerable. For this to happen, the unit must be a rewarding place to work, and a safe place to be.

Investigating suspected suicides: New Zealand coroners' experiences.

To understand how suspected suicides are investigated in New Zealand we conducted a thematic analysis of in-depth interviews with coroners. Coroners identified the inquisitorial nature of the coronial system and coroners' wide powers of jurisdiction as key strengths of the system. Important influences in key areas of coronial decision making in cases of suspected suicides included; the need for more evidence - especially to determine intent, and family factors, including therapeutic jurisprudence. Coroners identified lack of follow up and monitoring of recommendations, poorly resourced coronial training and the personal impact of suicides as challenges of working in the coronial system.

Learning from clinicians' positive inclination to suicidal patients: A grounded theory model.

Despite experts' contention that clinicians' positive inclination is essential to successful treatment of patients at risk for suicide (PRS), research in the area is lacking. This study used grounded theory to develop a model of clinicians' positive inclination based on interviews with 12 clinicians who "liked" working with PRS. The core process identified, a state of emotional synchrony through deep connection between clinicians and PRS, appeared to provide an intersubjective emotion regulation, associated with distress reduction in patients and deep satisfaction in clinicians. Findings suggest clinicians' deep sense of satisfaction and PRS' clinical improvement in treatment could be interdependent.

'Really there because they care': The importance of service users' interpretations of staff motivations at a crisis intervention service in New Zealand.

Crisis intervention services for people experiencing psychological distress and suicidal ideation are frequently described by the people accessing them as failing to meet their needs. This paper reports a prominent finding from a realist evaluation of Taranaki Retreat-a charitable, non-clinical organisation in New Zealand, which offers free respite for people experiencing acute distress. Using qualitative methods, the study aimed to move beyond vague notions regarding the helpfulness of respite, to a deeper understanding of the contextual factors and mechanisms which generate outcomes for such an intervention. Participant observation, focus groups with staff, semi-structured interviews with service users, and analysis of service users' case notes were conducted over a six-month period in 2018. The most prominent finding from the study related to 'genuine care'-care which is interpreted by the recipient as being motivated by a genuine desire to help. We present this finding as to the central mechanism in a wider programme theory developed through the realist evaluation study. We also present five key features of the care participants were offered at Taranaki Retreat which contributed to their common interpretation regarding the motivations behind this care. Upon considering the centrality of this mechanism we conclude that, in designing crisis interventions, greater consideration should be given to how the intervention can demonstrate genuine care. Having highlighted the ways in which the structure of charitable organisations appears conducive for interpretations of genuine care, we further conclude that the provision of comprehensive crisis intervention by charitable organisations should be further explored and supported.

There's no smoke without fire: Smoking in smoke-free acute mental health wards.

BACKGROUND: People who smoke with serious mental illness carry disproportionate costs from smoking, including poor health and premature death from tobacco-related illnesses. Hospitals in New Zealand are ostensibly smoke-free; however, some mental health wards have resisted implementing this policy. AIM: This study explored smoking in acute metal health wards using data emerging from a large sociological study on modern acute psychiatric units. METHODS: Eighty-five in-depth, semi-structured interviews were conducted with staff and service users from four units. Data were analysed using a social constructionist problem representation approach. RESULTS: Although high-level smoke-free policies were mandatory, most participants disregarded these policies and smoking occurred in internal courtyards. Staff reasoned that acute admissions were not the time to quit smoking, citing the sceptres of distress and possibly violence; further, they found smoking challenging to combat. Inconsistent enforcement of smoke-free policies was common and problematic. Many service users also rejected smoke-free policies; they considered smoking facilitated social connections, alleviated boredom, and helped them feel calm in a distressing environment - some started or increased smoking following admission. A minority viewed smoking as a problem; a fire hazard, or pollutant. No one mentioned its health risks. CONCLUSION: Psychiatric wards remain overlooked corners where hospital smoke-free policies are inconsistently applied or ignored. Well-meaning staff hold strong but anachronistic views about smoking. To neglect smoking cessation support for people with serious mental illness is discriminatory and perpetuates health and socioeconomic inequities. However, blanket applications of generic policy are unlikely to succeed. Solutions may include myth-busting education for service users and staff, local champions, and strong managerial support and leadership, with additional resourcing during transition phases. Smoke-free policies need consistent application with non-judgemental NRT and, potentially, other treatments. Smoking cessation would be supported by better designed facilities with more options for alleviating boredom, expressing autonomy, facilitating social connections, and reducing distress.

Occupational exposure to suicide: A review of research on the experiences of mental health professionals and first responders.

Exposure to suicide is a major factor for suicidality. Mental health professionals and first responders are often exposed to suicide while on-duty. The objective of this scoping review is to describe the state of current research on exposure to suicide among mental health professionals and first responders, focusing on the prevalence and impact of exposure to suicide, and to identify current gaps in the literature. We searched MEDLINE, Scopus, PsychNET, and Web of Science and identified 25 eligible papers. Between 31.5-95.0% of professionals had been exposed to suicide. Exposure to suicide had impacts on personal life, professional life, and mental health; and caused emotional distress. There was little research investigating exposure to suicide among police officers, firefighters, and paramedics. More research existed on mental health professionals, but none assessed exposure to suicide as a risk for suicide amongst this group. The review concludes that exposure to suicide is distressing for mental health professionals, and likely to be for first responder however, more research on these groups, especially paramedics, is required.

Silver linings of the COVID-19 lockdown in New Zealand.

The COVID-19 pandemic has caused significant disruption, distress, and loss of life around the world. While negative health, economic, and social consequences are being extensively studied, there has been less research on the resilience and post-traumatic growth that people show in the face of adversity. We investigated New Zealanders' experiences of benefit-finding during the COVID-19 pandemic and analysed qualitative responses to a survey examining mental well-being during the New Zealand lockdown. A total of 1175 of 2010 eligible participants responded to an open-ended question probing 'silver linings' (i.e., positive aspects) they may have experienced during this period. We analysed these qualitative responses using a thematic analysis approach. Two thirds of participants identified silver linings from the lockdown and we developed two overarching themes: Surviving (coping well, meeting basic needs, and maintaining health) and thriving (self-development, reflection, and growth). Assessing positive as well as negative consequences of the pandemic provides more nuanced insights into the impact that New Zealand's response had on mental well-being.

Fit for What Purpose? Exploring Bicultural Frameworks for the Architectural Design of Acute Mental Health Facilities.

Acute mental health care facilities have become the modern equivalent to the old asylum, designed to provide emergency and temporary care for the acutely mentally unwell. These facilities require a model of mental health care, whether very basic or highly advanced, and an appropriately designed building facility within which to operate. Drawing on interview data from our four-year research project to examine the architectural design and social milieu of adult acute mental health wards in Aotearoa New Zealand, official documents, philosophies and models of mental health care, this paper asks what is the purpose of the adult inpatient mental health ward in a bicultural country and how can we determine the degree to which they are fit for purpose. Although we found an important lack of clarity and agreement around the purpose of the acute mental health facility, the general underpinning philosophy of mental health care in Aotearoa New Zealand was that of recovery, and the CHIME principles of recovery, with some modifications, could be translated into design principles for an architectural brief. However, further work is required to align staff, service users and official health understandings of the purpose of the acute mental health facility and the means for achieving recovery goals in a bicultural context.

Young People's Perspectives and Understanding of the Suicide Story in 13 Reasons Why.

Background: The Netflix drama 13 Reasons Why (13RW) focusing on the suicide of an adolescent girl became a global phenomenon. It was accompanied by intense public debate about the risks of exposing youth to fictional portrayals of adolescent suicide. Aims: To explore adolescents' subjective perspectives and understanding of 13RW focusing on the portrayal of adolescent suicide. Method: We applied a thematic analysis to qualitative data from interviews with 25 New Zealand adolescents eliciting views on the show's portrayal of adolescent suicide. Results: Four themes were developed from the analysis: entertaining but not realistic; the unexpected shock factor; jumbled messages; and superficial conversations. Conclusion: This study contributes a youth perspective which has been missing from the debate on 13RW. This research highlights the way that youth, when given the opportunity, articulated a nuanced understanding of the representation of adolescent suicide in 13RW, viewing it as entertainment rather than a realistic depiction that added little in terms of suicide awareness and generated minimal opportunities for in-depth discussion.

Suicide and self-harm content on Instagram: A systematic scoping review.

Given concerns about suicide or self-harm content on Instagram, we conducted a systematic scoping review of peer-reviewed English language primary studies published between 2010-2019. Only ten studies had been published. Looking into purposive samples of Instagram posts tagged with self-harm related hashtags, studies report finding self-harm or suicide content in between 9-66% of their studied posts. Studies assessing Instagram's efforts to tackle such content found they had not been very effective. Despite heterogeneity in study aims, use of terminology, samples, methods of analysis, and study outcomes, we aggregated and distinguished 'content studies' and 'user studies'. Most studies showed concern for self-harm risk, but only one examined the relationship between self-harm posts and actual self-harm behaviours offline. It found such content had negative emotional effects on some users and reported preliminary evidence of potential harmful effects in relation to self-harm related behaviours offline, although causal effects cannot be claimed. At the same time, some benefits for those who engage with self-harm content online have been suggested. More research directly interviewing Instagram users to understand this phenomenon from their perspective is required. Finally, some ethical issues are discussed.

Systematic Exploration of Countertransference Phenomena in the Treatment of Patients at Risk for Suicide.

Despite its critical role in clinical suicidology, empirical evidence on the nature of countertransference (CT) to patients at risk for suicide (PRS) is lacking. This study aimed to provide a systematic description of CT phenomena to PRS. Psychiatrists, psychologists, and psychotherapists completed the Therapist Response Questionnaire (TRQ) online, with reference to a PRS. Factor analysis (n = 267) yielded a 7-factor structure, including 1) entrapped/rejecting, 2) fulfilled/engaging, 3) aroused/reacting, 4) informal/boundary crossing, 5) protective/overinvolvement, 6) ambivalent/inconsistent, and 7) mistreated/controlling. On average, clinicians reported that CT dimensions tended to not apply to them, except for the positively connoted factor. Our findings suggest that patients at risk for suicide elicit specific dimensions of CT. We offer two alternative interpretations of clinicians' CT endorsement patterns.

News Media Coverage of Stakeholder Views on Suicide and Its Reporting in New Zealand.

Background: Periodically, a debate around suicide reporting becomes prominent in the media. At one point, the Chief Coroner of New Zealand made a public call to the media to open up discussions around suicide and its reporting. Following this action, a high-profile debate emerged in the media. Aims: Our aim was to identify the key players in this debate and examine their perspectives. Method: From a Factiva search of news items from high-circulation newspapers, we identified key stakeholders and documented their perspectives using a framing matrix. Results: Seven stakeholder groups were identified with coroners and health service providers dominant in the news. Framing around the issues varied. There was consensus among the majority of stakeholders supporting continued public health type coverage of the issue of suicide, but a number of differences in levels of support for the reporting individual suicides. Limitations: Although specific to New Zealand, the findings will be of interest to countries considering reporting restrictions. Conclusion: The debate around suicide and its reporting appears to have been obfuscated by the conflating of two different types of media reporting on suicide: news media coverage of suicide as a public health issue and the reporting of individual suicide cases.

Prime Minister for a day: children's views on junk food marketing and what to do about it.

AIMS: This study explored children's awareness of and engagement with food marketing, and their views on action to address it. METHODS: A purposeful sample of 33 children (11-13 years) from the Wellington region of New Zealand were interviewed. RESULTS: Children were knowledgeable about food marketing, although most were not aware of the extent to which they were exposed. Children did not distinguish 'marketing to children' from other marketing. According to the children, they were frequently exposed to food marketing, and persuaded, against their better judgement, to purchase food they knew to be harmful to their health. As many children recognised the unhealthy nature of the food marketed to them, they agreed they would take action to reduce junk food marketing if they were Prime Minister for a day. Interventions included making food marketing honest, providing nutrition information, removing billboards and increasing the promotion of healthy food. CONCLUSIONS: These findings suggest children's exposure to junk food marketing may cause them physical, mental and moral harm, in direct contradiction of the New Zealand self-regulatory code for marketing. The children's views align with the World Health Assembly's recent decision to endorse initiatives to end childhood obesity, including restricting marketing of unhealthy foods.