A bite of dark chocolate? Black humour in mental health services.

OBJECTIVE: Black humour permits expression of what may otherwise be unspeakable and is observed and used by staff working in mental health services. The aim of this study was to identify how humour, particularly black humour, was perceived by different health professionals in psychiatric practice. METHODS: Participants were invited to complete a survey. Data was collated and statistically analysed by a biostatistician. Chi square and univariate tests were performed to identify associations between categories. RESULTS: The sub-question relating to the benefits of black humour was analysed. Main findings were that the majority of staff perceived black humour to be beneficial in psychiatric practice (n = 564 of 710 total; 79.4%), particularly if they used general and black humour with patients, families and colleagues. Those who observed black humour being used collegially about patients and families were more likely to find black humour beneficial; and even those uncomfortable with black humour being used by colleagues were more likely to see the benefits of black humour. CONCLUSION: Black humour was perceived to be beneficial in mental health settings when used mindfully, sensitively and in context. Further study with patients and relatives may shed light on how widely the perception of benefit is shared.

Tracking the 3-year trajectory of referrals to an early psychosis intervention service.

AIM: To review the baseline and clinical characteristics of patients referred to a New Zealand Early Psychosis Intervention (EPI) service across a 4-year timeframe. METHOD: We compared two cohorts, and identified variables associated with being accepted or declined, and reasons for decline, by an EPI service between 2013 and 2017. RESULTS: There were 576 people with suspected psychosis referred to the EPI service for assessment: 300 (52%) were accepted, 221 (38%) declined and 55 (10%) were not processed. Reasons for being declined by EPI services were a long duration of psychosis (DUP, 48%) and no evidence of psychosis (47%). There were no significant differences between the accepted and declined group in Emergency Department presentations for self-harm or suicide attempts and acute admissions to a psychiatric inpatient unit over the 3-year follow-up period. CONCLUSION: To optimise the identification of true positive cases, EPI services require clear entry criteria. Replicating this study in other EPI services with different entry criteria may provide evidence to develop a more uniform screening process. Improved outcomes may be enhanced by measuring effectiveness and liaising with other EPI services.

Modelling vulnerability: qualitative study of the Balint process for medical students.

BACKGROUND: Health professionals in training may be overwhelmed by the emotional dimensions of their work. Balint groups have been proposed as an intervention to support students to process emotional aspects their encounters with patients. The aim of this study was to explore medical students' emotional experiences of a Balint group during their psychiatry attachment. METHODS: Medical students completing a six week clinical attachment in psychiatry took part in weekly Balint group sessions. Five sessions were audio-recorded, transcribed and coded by members of the research team and an independent researcher co-coded all transcripts. Themes were discussed and refined over three rounds of coding. RESULTS: Four themes were identified: the Balint process as a container to enable vulnerability; becoming attuned to clinical and professional encounters; an evolving sense of identity within the medical hierarchy; and, the need for self-preservation to retain empathy for others. CONCLUSION: The Balint structure provides medical students with a secure and emotionally resonant experience. Medical students' engagement with the Balint process, even over a relatively short time period, teaches them how to reflect on difficult emotions associated with clinical encounters. Early exposure during a psychiatry placement may benefit students in terms of understanding relationship dynamics and the need for self-integration and lifelong reflection over the course of their medical career.

Stigma in Consultation Liaison Psychiatry: A Qualitative Study of Trainee Psychiatrists.

OBJECTIVE: Stigma related to mental illness can impact service-user care and clinician wellbeing. The aim of this study was to explore experiences of stigma in consultation-liaison psychiatry from the perspectives of trainee psychiatrists and suggest interventions to tackle stigma within a hospital environment. METHOD: Ethics approval and consent were obtained for the study. In-depth interviews were conducted by telephone with six participants in four New Zealand district health boards. De-identified data was analysed using thematic analysis. An independent co-coder was employed to enhance analytic rigour. RESULTS: Participants experienced stigma during their consultation-liaison rotations. Some felt isolated and undervalued. Education, intergration and role clarification within the hospital environment were identified as ways to reduce stigma. CONCLUSIONS: Stigma experienced by trainee psychiatrists completing consultation-liaison rotations may lead to them feeling devalued and perceiving service-users to experience poorer care. Multidisciplinary education may potentially combat stigma and contribute to improved integration of services.

Audit of acute psychiatric presentations during New Zealand's first COVID-19 national lockdown.

OBJECTIVE: In this study, we aimed to identify service user demographic and clinical characteristics of an acute mental health service in South Auckland during the first New Zealand coronavirus-related lockdown. METHOD: We conducted a clinical audit of a sample of service users presenting to a district health board's acute adult mental health service during New Zealand's level-4 lockdown in 2020 and made comparisons to a sample from 2019. We identified demographic factors, living situation, mode of referral, mode of assessment, diagnosis, substance use, risks, stressors, use of mental health act legislation and follow-up. RESULTS: During the first level-4 lockdown fewer Ma¯ori were assessed, police referrals increased, specific stressors related to confinement were identified and there was an increase in risks relating to self-harm and harm to others. CONCLUSION: Service users had unique stressors and changing patterns of presentation during the level-4 New Zealand lockdown. In response to the changing needs of service users during a pandemic, we recommend optimising telehealth, enhancing connections with other essential services, development of digital interventions and care for frontline staff.

Clinicians' experiences of inquiries following mental health related homicide: a qualitative study.

OBJECTIVES: This aim of this qualitative study was to explore the experiences of clinicians involved with inquiries into the mental health care of patients who were perpetrators of homicide in New Zealand. METHODS: Our purposive sample comprised ten clinicians working in New Zealand district health board mental health services. These clinicians were individually interviewed. Interviews were audio-recorded, transcribed and thematically analysed. The coding framework was checked and peer reviewed by an independent researcher. RESULTS: Five themes were identified: the inquiry process; emotional burden; impact on team dynamics; changes to individual clinical practice; and perceptions of inquiries being influenced by organisational culture. Clinicians involved with inquiries reported significant anxiety and disrupted multidisciplinary team dynamics. Some participants found inquiries led to changes to their clinical practice and perceived that a punitive organisational culture limited learning. CONCLUSIONS: Clinicians perceived inquiries as threatening, anxiety provoking and primarily concerned with protecting organisational interests. Communication of the inquiry process and ensuring inquiry findings are disseminated may enhance clinicians' experiences of inquiries and facilitate their participation and their reflection on changes to clinical practice that could contribute to improving services. Support for clinicians and multidisciplinary teams should be emphasised by the commissioning agency.

The conduct of inquiries: a qualitative study of the perspectives of panel members who investigate mental health related homicide.

BACKGROUND: Inquiries into mental health related homicides may be held to identify failures in care and areas for improvement, accountability and to enhance public confidence. However, inquiries do not always achieve these aims. AIM: The aim of this study was to explore the perspectives of members of inquiry panels who conduct inquiries into mental health related homicides in order to identify elements that would constitute a good inquiry. METHODS: We selected a sample of inquiry panel members comprising 15 senior clinicians, legal experts and consumer advisors. Semi-structured interviews were audio-recorded, transcribed and analysed using thematic analysis. RESULTS: Participants raised concerns related to: (1) orientation of the panel to the inquiry task; (2) clarity of the process; and (3) impact of the inquiry. Most participants recognised that inquiries require a focus on mental health systems and sensitivity to families and clinicians. They reported difficulties in clarifying purposes, attending to cultural aspects of the case, having a clear method tailored to the mental health context, formulating recommendations and disseminating findings. CONCLUSIONS: Our participants perceived a number of weaknesses in the process by which inquiries into mental health related homicides had been conducted, and recommendations formulated and implemented. There is an opportunity to address these and thereby potentially improve the effectiveness and value of inquiries.

Mental Health Inquiries in the Case of Homicide.

We aimed to identify features of New Zealand government-commissioned inquiries into the provision of mental health services after homicides committed by service users. The analysis of five reports from 1992 to 2016 identified similarities across reports, which included documenting a process; responding to a set terms of reference; detailing a case chronology, risk assessment, team and system issues; making recommendations and giving opportunities to clinicians to respond to adverse comments. Differences included selecting key informants and acknowledging limitations of scope. The inquiries did not specify a means to disseminate findings to stakeholders and follow up recommendations. Unrealised opportunities include attention to relationships between stakeholders and ways to support learning from inquiries. There is no standardised approach to conducting statutory inquiries into mental health services following a homicide. This limits the value of such inquiries for learning and service improvement. We recommend a standardised framework be developed to guide inquiries.

Documenting psychiatric risk: more than ticking boxes.

OBJECTIVE: The purpose of this study was to audit the completion of risk assessment documentation by staff working within an acute adult mental health setting. METHOD: Fifty risk assessment forms in a district health board's acute adult mental health service were audited for completion. Clinicians provided verbal feedback on the audit results. RESULTS: Risk assessment forms were completed in 58.3% of cases. A risk formulation statement was completed in 43.8% of cases. Rates of completion varied between senior medical officers, registrars and nurses. CONCLUSION: Accurate risk formulation and safety planning are more important than ensuring all boxes are ticked on a form. Optimising the design of electronic forms may enhance access to information about historical risk.

Appreciative Inquiry in Psychiatry Peer Groups.

OBJECTIVE: The purpose of the study was to explore the feasibility of using appreciative inquiry in a peer group of psychiatry residents. METHODS: A peer coaching exercise using appreciative inquiry was modeled to a group of psychiatry residents who practised the approach. The topics discussed in separate sessions 1 month apart were values and identity as a psychiatrist, dealing with conflict and working within the psychiatric system. Following each session, the residents participated in focus group interviews. Transcripts were thematically analyzed and independently coded. RESULTS: Four themes were identified: (i) connectedness, (ii) a structure for dialogue, (iii) reflection, and (iv) generative conversations. CONCLUSION: Appreciative inquiry is a feasible method to facilitate focused and meaningful encounters and develop connection between members of a peer group.

The crucible of early career psychiatry.

OBJECTIVE: To capture the voices of psychiatrists as they reflect on challenges at the early stages of the career trajectory. METHOD: Early career psychiatrists contributed reflections that identified various challenges in the transition from trainee to consultant psychiatrist. RESULTS: Common difficulties included negotiating role transition and conflict. Specific events had deep impact such as involvement with a patient who had committed suicide. CONCLUSIONS: Challenges in the early career stage as a consultant psychiatrist may have lasting or career defining impact. Written reflection is a valuable tool that can impart collective learning, provide validation and engender support among peers.

Leadership mindset in mental health.

OBJECTIVES: The objective of this study was to explore the concept of mindset for psychiatrists who are considering stepping into the leadership arena. METHODS: Qualitative themes were extracted from dialogue on leadership development at a Royal Australian and New Zealand College of Psychiatrists forum for early career psychiatrists. RESULTS: Three key themes were identified: adapting to a professional identity as psychiatrists; developing a mindset for leadership; and acting intentionally to seek opportunities for leadership. CONCLUSIONS: Shifts in professional identity occur in the transition from trainee to specialist as early career psychiatrists become increasingly aware of broad systemic factors in clinical care. The concept of a mindset, distinct from a skillset of knowledge and expertise, may be an emergent quality for psychiatrists who are seeking to develop their leadership potential.

Supervising trainees in research: what does it take to be a scholarly project supervisor?

OBJECTIVES: Scholarly projects (SPs) are a compulsory component of psychiatry training in Australasia. This article outlines the role of a research supervisor in supporting a trainee to complete an SP. METHODS: A total of 10 old age and forensic psychiatry SPs were reviewed with regard to aims, methodology, supervisor input, trainee tasks and additional resources. RESULTS: The main supervisor tasks are described and discussed. They include practical advice on study design, ethics applications, critical appraisal, data analysis, academic writing and publication. CONCLUSIONS: Supervising SPs can bring significant rewards in awakening a trainee's interest in research. Key competencies for research supervision are discussed and further recommendations for supervisor support and training are provided.

Transforming an idea into a scholarly project.

OBJECTIVES: This article describes components of a workshop designed to orientate psychiatric trainees to the task of conducting a scholarly project. The aims are: to promote an approach that incorporates principles of adult learning to guide trainees who are undertaking research; to allow trainees to transform their ideas into more tangible research questions; and to enable supervisors to reflect on delivering similar content in scholarly project workshops. METHODS: The workshop comprised: creating a safe space to explore ideas; discussing the process of posing a question or hypothesis; using group interactions to generate concepts; and considering personal values that influence the choice of research methodology to answer a question. RESULTS: Examples are provided from the workshop. The process enabled trainees to generate and distil ideas into more concrete questions and methods in three phases: introductory, exploratory and tangible. CONCLUSIONS: Adult learning principles may assist trainees to develop their ideas for a scholarly project into research questions that are relevant to clinical practice. Harnessing the creative potential of a peer collective may encourage deeper inquiry, shifts to a tangible output and a sustained interest in research.

Thinking on writing a critical essay.

OBJECTIVE: To provide a strategy for writing a critical essay for the Royal Australian and New Zealand College of Psychiatrists examination using a sample question. CONCLUSION: To prepare for writing a critical essay, candidates are advised to read widely and critically, to practise writing essays with a clear structure under examination conditions and seek constructive critique from colleagues. This will help them to write succinctly and develop a reasoned argument that is relevant to the quotation.

The infant observation task as a tool in psychiatric practice.

OBJECTIVE: The objective of this study was to describe the method and relevance of infant observation as a unique and powerful learning tool for psychiatrists. CONCLUSION: Infant observation provides a privileged entry into an infant's internal world to observe its earliest mental life. Weekly consecutive observations of the mother-baby dyad, combined with the process of supervision, enable identification of emergent and changing patterns in the relationship. The discipline of observation encourages attunement to the nuances of relationships, which provides a potent tool for application in other clinical settings.

Things I wish I'd known: desiderata for early career psychiatrists.

OBJECTIVE: The objective of this study was to disseminate advice imparted to early career psychiatrists by a panel of senior colleagues at a Royal Australian and New Zealand College of Psychiatrists symposium, reflecting on things they wished they had known at the earlier stage in their careers. METHODS: Key themes were extracted from notes taken at the symposium, where opinions were expressed by three senior psychiatrists. RESULTS: There are components in building a sustainable career as a psychiatrist, which include considering one's work environment and relationships with colleagues; self-care, mentorship and reflective practice; and seeking opportunities to teach and research for career progression. CONCLUSIONS: The mentorship and advice from senior colleagues can be highly influential. In order to sustain a career that has reward, meaning and longevity, psychiatrists would do well to pay attention to aspects of self-care, stay connected to their loved ones, seek an optimal work-life balance and take an interest in their long term career plans.

Testifying in a mock court: the experiences of forensic advanced trainees.

OBJECTIVES: We aimed to examine the experiences of advanced trainees in forensic psychiatry as they practise testifying as expert witnesses in a mock court setting. METHODS: Five advanced trainees (including the first author) submitted court-ordered forensic reports in advance of attending the mock court. Senior colleagues had roles of Judge, prosecution and defence lawyers. House officers and medical students were summoned as jury. Over a year, each trainee had the experience of direct and cross-examination by opposing legal teams. Following the mock trial, each participant was given immediate feedback and subsequently asked to complete a semi-structured questionnaire. RESULTS: The experience of participating in a mock court has learning value for advanced trainees specialising in forensic psychiatry in anticipation of giving evidence in a court of law. Constructive feedback enabled attendees to gain valuable education in a supportive setting. Of particular value was guidance in the use of technical language in presenting evidence in a court setting, knowledge of the breadth of questions that could be put forth to an expert witness, desensitisation training in an adversarial albeit simulated setting, and acquiring skills in staying calm under pressure. CONCLUSIONS: The importance of a well-written report, good preparation and anxiety management were significant learning points.

Text2whaiora after a suicide attempt: Text message design alongside people with lived experience.

BACKGROUND: People with lived experience have had limited opportunities to meaningfully contribute to the design of caring contacts interventions. The objective of this study was to co-design text messages with peer support specialist staff to determine optimal language and delivery, within a cultural context. METHODS: In this qualitative study, participants were professional peer support specialist staff with lived experience employed by specialist mental health services. They were asked to evaluate the initial series of text messages by taking part in a focus group using a semi-structured interview. This was audiotaped, transcribed and analysed using reflexive thematic analysis with specific coding of cultural themes. RESULTS: Three main themes were identified: upholding a person's autonomy; establishing connection as a bridge to safety; and, words as healing rongoa (remedy). The last theme contained a cultural subtheme: Maori language providing entry to the Maori world. CONCLUSION: People with lived experience breathe empowerment and hope into caring contacts interventions and should be considered vital partners in developing any suicide prevention initiative. Feeling genuinely cared for promotes connection and may enable an internal sense of safety. Tailoring of texts can be enhanced by culturally nuanced language.

Psychiatric trainees' experiences of workplace violence: qualitative analysis.

AIMS AND METHOD: We aimed to explore experiences of workplace violence in a New Zealand sample of psychiatric trainees and to identify barriers to achieving safe practice and ways of enhancing workplace safety. In a qualitative study, we used interpretive description to inform and design in-depth exploration of participants' experiences. We interviewed 12 psychiatric trainees. Data were analysed using reflexive thematic analysis. RESULTS: There were three main themes: (a) violence as 'part of the job', leading to a culture of silence; (b) empowering trainees to address a sense of learned helplessness; and (c) conflict embedded within the unique nature of psychiatry. CLINICAL IMPLICATIONS: Organisation-led systems-based procedures are instrumental in promoting workplace safety. Specific measures include peer-based support and implementing clear, tailored safety protocols, particularly for situations of crisis assessment. Training should include culturally focused education with specific guidance to mitigate violence.