Exploring the lived experience of receiving mental health crisis care at emergency departments, crisis phone lines and crisis care alternatives.

BACKGROUND: Mental health crisis care includes emergency departments (EDs), crisis phone lines and crisis alternatives. Currently, there is an overreliance on EDs to provide mental health crisis care, with evidence that responses are often inadequate to meet the needs of people experiencing mental health crises. However, the complexities of how individuals experience crisis care across the varying contexts of EDs, crisis phone lines and crisis alternatives remain underresearched. METHOD: This study used a hermeneutical phenomenological approach to understand the lived experience of accessing care during a mental health crisis. Thirty-one Australian adults who had accessed crisis services at ED, phone lines and/or crisis alternatives participated in in-depth interviews. RESULTS: The findings are organised across the temporal narratives of participants' experiences from (1) point of contact, (2) positive and negative care experiences and (3) enduring impacts. Several themes were generated during these phases. The findings demonstrate the interrelated nature of care experiences and enduring impacts. With some exceptions, care received within EDs was harmful, resulting in lasting adverse effects. Responses from crisis phone lines were mixed, with participants appreciating the accessibility of after-hour phone support but finding standardised risk assessments unhelpful. Responses from crisis alternatives to ED were promising, aligning with the need for validation and human connection, but were not always accessible or easy to mobilise during a crisis. Notably, across all settings, positive effects were firmly attributed to the quality of the relationship with specific crisis providers. CONCLUSION: The findings bring into sharp focus the lived experience of people accessing crisis care and contribute to the shortage of literature on subjective experiences. Providers may better meet the needs of those experiencing mental health crises by understanding the enduring impact of these interactions and the role of human connection beyond a focus on risk assessment, thereby providing opportunities for a joint understanding of risk and meaning-making. Furthermore, understanding the subjective experience of crisis care can guide reforms to ED and develop crisis alternatives to better meet the needs of people in crisis. PATIENT OR CONSUMER CONTRIBUTION: The first author and the third author are in designated lived experience (Consumer) roles. The first author conducted the interviews and was explicit regarding their lived experience when engaging with participants. Service users were involved as advisors to the study and provided input into the design.

Our Wished-for Responses: Recommendations for Creating a Lived and Embodied Sense of Safety During Mental Health Crisis.

BACKGROUND: Medical interventions have a place in crisis support; however, narrow biomedical and risk-driven responses negatively impact people seeking crisis care. With increasing shifts towards involving people with lived experience (service users) in designing services, foregrounding people's desired responses is critical. Accordingly, the aim of the study was to explore the wished-for crisis responses from the perspective of people who have experienced crisis and accessed crisis care. METHOD: Using a hermeneutical phenomenological approach, in-depth interviews were conducted to determine the desired crisis responses of 31 people who self-reported experiencing mental health crises and accessed crisis services at ED, phone lines and/or crisis alternatives. RESULTS: The findings identified wished-for responses that gave a felt and embodied sense of their own safety influenced by a human-to-human response, emotional holding, a place of safety and choice within holistic care. For such responses to be possible, participants identified organising principles, including recognising crisis as meaningful and part of our shared human experience, understanding risk as fluid and a whole-of-community responsibility for responding to crises. CONCLUSION: This paper proposes how insights from people who have experienced crises can be translated into more beneficial crisis care. PATIENT OR CONSUMER CONTRIBUTION: Most authors are in identified lived experience roles. The first author engaged with participants during the recruitment and interviews and was explicit regarding their lived experience. Service users were involved as advisors, providing input throughout the study.

Mental Health First Aid crisis role-plays between pharmacists and simulated patients with lived experience: a thematic analysis of debrief.

PURPOSE: Healthcare professionals, including pharmacists, can recognise and assist people experiencing mental health crises. Despite this, little is known about how pharmacists assist and engage with people presenting with signs and symptoms of mental health crises. This study aimed to (i) examine pharmacists' mental health crisis assessment language during simulated patient role-plays (SPRPs) and (ii) explore participants' experiences of participating in SPRPs of Mental Health First Aid (MHFA) scenarios. METHODS: Fifty-nine MHFA-trained pharmacy staff participated in audio-recorded SPRPs of three crisis scenarios enacted by a mental health consumer educator (MHCE). Post-SPRP, pharmacy staff members (including role-playing and observing participants), engaged in reflective debrief discussions with the facilitator and MHCEs. Debrief discussions were transcribed verbatim and analysed using inductive thematic analysis and suicide assessment language was explored. RESULTS: The majority of role-playing pharmacists asked about suicidal ideation using appropriate, direct language (n = 8). Qualitative analyses of debrief discussions yielded four themes: (i) Relationship with the consumer, (ii) Verbal and non-verbal communication, (iii) Challenges with crisis assessment, which included difficulties associated with initiating conversations about suicide and mania, and (iv) Reflective learning. CONCLUSION: While pharmacists demonstrated the appropriate suicide assessment language post-MHFA training, pharmacists felt uncomfortable initiating conversations around suicide and lacked confidence during crisis assessments. SPRPs provided pharmacists with opportunities to reflect on and practice MHFA skills in a safe learning environment. Future research exploring how MHFA training and SPRPs impact pharmacists' ability to provide MHFA in real-world settings is warranted.

Pharmacist-led interventions for people living with severe and persistent mental illness: A systematic review.

OBJECTIVE: People living with severe and persistent mental illness experience poorer physical health, often due to medication and preventable lifestyle factors, and exacerbated by barriers to accessing healthcare services. Pharmacists are well-positioned to improve the physical and mental health of this population. However, little is known about pharmacists' current practices when providing services to this population nor the impact of pharmacist-led interventions on consumer health outcomes. We undertook a systematic review to identify, describe and assess the effectiveness of pharmacist-led interventions for supporting people living with severe and persistent mental illness and the impact on consumer outcomes. METHODS: MEDLINE, Embase, PsycINFO, CINAHL, Web of Science, Scopus, Cochrane Library, International Pharmaceutical Abstracts and ProQuest Dissertations and Theses were searched between January 1990 and April 2020. Full-text studies exploring pharmacist-led interventions in any setting for people living with severe and persistent mental illness were included. A risk of bias assessment was conducted. RESULTS: A total of 37 studies were included. More than half of the pharmacist interventions were multifaceted. The most common components of pharmacist-led interventions included education and/or patient counselling, providing recommendations to healthcare professionals and conducting medication reviews. Multifaceted interventions demonstrated improvements in clinical outcomes, whereas single interventions focused mostly on consumer-reported outcomes. The methodological quality of included studies was moderate-to-high risk of bias and there was considerable heterogeneity in the study design, interventions described, and outcomes reported. CONCLUSION: There is evidence that pharmacist-led interventions improve consumer-reported and clinical outcomes for people living with severe and persistent mental illness. Pharmacists are capable and have a role in supporting people living with severe and persistent mental illness, either individually or as interprofessional collaborators with other healthcare professionals. Future research should attempt to better understand which particular intervention components have the greatest impact and also evaluate the implementation and long-term sustainability of such interventions.

Effective Peer Employment Within Multidisciplinary Organizations: Model for Best Practice.

This study sought a clearer understanding of organizational mechanisms reinforcing effective peer employment and organizational change from the perspectives of peer workers, non-peer staff and management in multidisciplinary mental health and substance use recovery services. Findings were used to develop a model for organizational best practice for peer employment and associated organizational change to promote recovery-oriented and person-directed services. Qualitative research was undertaken, involving 132 people participating in 14 focus groups and eight individual interviews. These people were employed across five U.S. multidisciplinary organizations providing mental health and substance use recovery services and deemed by a panel of experts to provide effective employment of peer workers. Study findings include the articulation of an interactive working model of best practice, comprising organizational commitment, organizational culture and effective organizational strategies necessary for a "whole-of-organization" approach to support authentic peer work and enable organizational transformation, to actualize recovery-oriented values and person-driven services. Strategies include Human Resources engagement, peers in positions of senior organizational authority, recurring whole of workforce training, along with peer training and peer-led supervision. Findings suggest whole-of-organization commitment, culture and practice are essential for the organizational transformation needed to support effective employment of peers in multidisciplinary environments.

How health care systems let our patients down: a systematic review into suicide deaths.

PURPOSE: To synthesize the literature in relation to findings of system errors through reviews of suicide deaths in the public mental health system. DATA SOURCES: A systematic narrative meta-synthesis using the PRISMA methodology was conducted. STUDY SELECTION: All English language articles published between 2000 and 2017 that reported on system errors identified through reviews of suicide deaths were included. Articles that reported on patient factors, contact with General Practitioners or individual cases were excluded. DATA EXTRACTION: Results were extracted and summarized. An overarching coding framework was developed inductively. This coding framework was reapplied to the full data set. RESULTS OF DATA SYNTHESIS: Fourteen peer reviewed publications were identified. Nine focussed on suicide deaths that occurred in hospital or psychiatric inpatient units. Five studies focussed on suicide deaths while being treated in the community. Vulnerabilities were identified throughout the patient's journey (i.e. point of entry, transitioning between teams, and point of exit with the service) and centred on information gathering (i.e. inadequate and incomplete risk assessments or lack of family involvement) and information flow (i.e. transitions between different teams). Beyond enhancing policy, guidelines, documentation and regular training for frontline staff there were very limited suggestions as to how systems can make it easier for staff to support their patients. CONCLUSIONS: There are currently limited studies that have investigated learnings and recommendations. Identifying critical vulnerabilities in systems and to be proactive about these could be one way to develop a highly reliable mental health care system.

Partners in Recovery: paving the way for the National Disability Insurance Scheme.

Australians experiencing severe and persistent mental illness and who require services from multiple agencies, experience a fragmented service delivery system. In 2014, the Commonwealth Government introduced the Partners in Recovery (PIR) service, which provides service coordination and flexible funding to improve outcomes for this group of people. This study presents qualitative findings from a research project that aimed to understand the experiences of PIR participants, including aspects of the planning process and the effectiveness of the PIR program in meeting their needs from the perspective of the participant, their carer or family member and other support people within their lives. Semi-structured interviews were conducted with 31 stakeholders involved in the PIR program, of which 14 were participants, 17 were members of the participant's support network and three were members of a consumer and carer advisory group. Overall participation in the PIR program had a positive effect on the participant's lives. Relationships with the support facilitators were seen as an important element of the process, along with a focus on recovery-oriented goals and advocacy and linking to other agencies. These findings are important for informing the roll-out of the National Disability Insurance Scheme in Australia, which will replace PIR.

The anatomy of crisis.

This phenomenological study deeply explores the individual and collective lived experience of a mental health crisis. A Lifeworld approach provided the entry point to deeper insights into the anatomy of crisis as the embodied emotional, physical, cognitive, and spiritual nature of crisis. Findings uncovered rich descriptions of mental health crises and how the crisis was encountered in a shattered sense of self and relational challenges in the context of receiving crisis care. Overall, the study revealed an embodied understanding of crisis that offers practical direction in providing crisis care that is more attuned to lived experience.

Differences and Similarities Between Consumer- and Caregiver- or Family-Informed Peer Roles in Mental Health.

OBJECTIVE: Peer workers are widely employed across the mental health sector in Australia, and these positions increasingly include people with experience as a service user (consumer peer workers) and people with experience as a family member (caregiver peer workers). The authors explored similarities and differences between the consumer and caregiver peer workforces and considered positions designed to combine consumer and caregiver perspectives. METHODS: A mixed-methods design was used to analyze data from a nationwide Australian survey (N=882), including responses from peer staff with consumer and caregiver perspectives (N=558), and from mental health staff not designated as peer workers (N=324). RESULTS: Most participants viewed the two perspectives as different in terms of values or goals (51%) and work practices (59%), with fewer stating that the two workforces had similar goals or values (45%) and work practices (37%). Qualitative findings provided insight into these differences and similarities, identifying differences in perspectives, priorities, and work practices but highlighting similarities in values between the two workforces. Qualitative data also revealed potential risks of employing peer workers in roles designed to use both kinds of experience for direct support roles but indicated potential for the combined perspective in other contexts. Both qualitative and quantitative data indicated that participants with consumer experience perceived greater differences between the role types than those with caregiver experience only. CONCLUSIONS: The findings indicate similarities and differences between staff with consumer or caregiver perspectives and highlight the need for greater role clarity and the potential for conflict in positions where peer workers combine both perspectives.

Supervision of the mental health lived experience workforce in Australia: A scoping review.

The mental health Lived Experience workforce (also referred to as peer workforce) is growing rapidly internationally and within Australia. Peer workers are increasingly employed within multi- and inter-disciplinary teams, often directly supervised by mental health professionals such as nurses. Professional supervision has been identified as fundamental for implementing a sustainable peer workforce, but significant gaps in the literature remain, in particular, an understanding of appropriate supervision practices. This scoping review synthesized academic and grey literature on Lived Experience supervision in Australia, exploring current thoughts on best practices. Four electronic databases were searched, and grey literature was located via Google Advanced searches, contacting Lived Experience experts and conducting web-based desktop searches of key mental health organization websites. Thematic analysis identified and described key characteristics in relation to how supervision is conceptualized and operationalized. Eight peer-reviewed and 46 grey literature documents describing supervision and supervisory practices were analysed. Of these studies, 26 were Lived Experience-led. Analysis revealed four key themes: (i) defining peer supervision, (ii) variability in understanding the purpose of supervision, (iii) approaches to supervision and the need for choice and flexibility, and (iv) qualities and skills of the supervisor. Additionally, the establishment of a national professional organization for peer workers was highlighted to protect the authenticity of Lived Experience roles and develop an effective workforce. Clearly, a sustainable Lived Experience workforce cannot develop in isolation, and mental health nurses, as important allies in mental healthcare, need to work alongside, plan and advocate for appropriate supervision practices for this emerging workforce.

Implementing a randomised controlled trial through community pharmacies to support people living with severe and persistent mental illness: Lessons learnt during the COVID-19 pandemic.

Public health orders were introduced in many countries, including Australia, during the COVID-19 pandemic to reduce the spread of the virus. However, for many people this led to an exacerbation of mental health symptoms, particularly those living with severe or persistent mental illness (SPMI). Additionally, the conduct of clinical research was severely impacted during the pandemic, with many difficulties encountered in the conduct of clinical trials. This paper describes the COVID-related impacts experienced during the implementation of a randomised controlled trial (RCT) testing the effectiveness of a community pharmacist-led support service for people living with SPMI in Australia (the PharMIbridge RCT), and the strategies used to successfully implement the RCT. Australian public health orders led to interstate border closures, stay-at-home orders and work-from-home requirements, resulting in necessary changes to allow for the continuation of the RCT including; changes to trial regions, transferring some training materials online while delaying face-to-face (F2F) training components, delays in pharmacy and consumer recruitment, encouraging telehealth service delivery and extensions to timelines with existing funding. Having a solution-focussed and flexible approach, while still ensuring critical trial protocol elements were adhered to, such as providing opportunities for F2F skills-based training for pharmacists, as well as F2F site visits from researchers and mentors to support trial implementation, resulted in high pharmacy and consumer participant retention through to trial conclusion. Future planning for RCTs should consider possible pandemic-related risks and rapid responses from approval bodies to ensure researchers can be agile and adapt to ensure successful trial completion.

To disclose or not to disclose? Peer workers impact on a culture of safe disclosure for mental health professionals with lived experience.

The presence of peer workers in multi-disciplinary environments has rapidly increased in recent years, yet the impact of peer work on other mental health roles is largely unknown. This article explores the presence of peer workers within multi-disciplinary environments, with a specific focus on the possible impact of this presence on the culture of disclosure for mental health professionals with lived experiences of mental health challenges. Semi-structured focus groups and interviews were conducted with 132 participants at five organizations across the United States. Participants self-identified as being employed in a range of roles including management, mental health professionals, designated peer workers, and designated peer leadership positions. Findings suggest intentionally employing peers and using peer values to address stigma toward mental health professionals improves the culture of disclosure. In work environments where peer-led initiatives were featured, mental health professionals felt safer disclosing their own lived experience to their colleagues and supervisors. Recommendations include the use of parallel strategies to promote the perceived value of peers and to implement peer-led training for both supervisors and professionals to model a workplace culture that promotes and supports self-disclosure in the organization. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Peer support work for people experiencing mental distress attending the emergency department: Exploring the potential.

OBJECTIVE: This study explored the benefits and limitations of employing peer support workers, who utilise their own lived experience of mental distress and recovery, to support people experiencing mental distress who are attending the ED. METHODS: This co-produced qualitative study utilised four phases: (i) assemble a collaborative multi-disciplinary research team and Expert Panel, of which at least half identified as having lived experience; (ii) a site visit to an ED; (iii) focus groups with consumers, support persons and ED staff; and (iv) a learning workshop for peer workers. RESULTS: Focus groups were run for consumers (n = 7), support persons (n = 5) and ED staff (n = 7). Eleven consumer peer workers participated in the learning workshop. Four themes were identified and triangulated: the individual in distress, peer support work, a 'Peers in EDs' service and the ED context. Overall, findings suggest that peer support workers contribute important skills including listening, de-escalation, relationship-building and empathy. CONCLUSIONS: This study identified that peer support workers would bring important skills to an ED (e.g. empathetic support, de-escalation). However, significant workforce and organisational support would be required.

Skin in the game: The professionalization of lived experience roles in mental health.

The lived experience workforce has moved from being a grassroots support and activist movement to become the fastest growing workforce within mental health. As lived experience work becomes assimilated within mainstream mental health service delivery, it faces mounting pressure to become more professionalized. Professionalization has evoked both optimism and fear, with diverging views within the lived experience workforce. In this paper, an assessment of the existing professionalization of the lived experience workforce is undertaken by drawing on theoretical positions and indices of what constitutes a profession. The arguments for and against professionalization are explored to identify the risks, benefits, and considerations for the lived experience workforce. The drive for professionalization has largely occurred due to the clinically focused mental health systems' valuing of professional identity. The argument in favour of professionalization is motivated by a need for credibility within the views of that system, as well as greater regulation of the workforce. However, tensions are acknowledged with concerns that professionalization to appeal to the clinically focused system may lead to erosion of the values and uniqueness of lived experience work and nullify its effectiveness as an alternative and complementary role. Given mental health nurses are increasingly colleagues and often line managers of lived experience workers, it is important at this stage of lived experience workforce development that mental health nurses understand and are able to advocate for lived experience roles as a distinct professional discipline to help avoid the risks of co-option to more dominant clinical practice.

Exploring goal planning in mental health service delivery: a systematic review protocol.

INTRODUCTION: Goal planning is widely recognised as an integral part of mental health service delivery and an important element in supporting recovery. Goal planning identifies priorities for treatment through discussion and negotiation between service users and health practitioners. Goal planning enhances motivation, directs effort, and focuses the development of strategies and treatment options to improve recovery outcomes and promote service users' ownership of the recovery process. While goal planning is a common practice in mental health settings, evidence regarding its impact on treatment outcomes is lacking. This paper outlines a protocol for a systematic review that aims to explore the types of goals planned, experiences of service users and practitioners, and the effectiveness of goal planning as a mental health intervention. METHODS AND ANALYSIS: A systematic search will be conducted during March 2021 by searching Medline, CINAHL, Embase, Scopus and PsycINFO electronic databases to answer the following questions: (1) What types of goals are being developed within mental healthcare?; (2) What is the evidence for the effectiveness of goal planning on health and well-being for mental health service users?; (3) What are the experiences of mental health service users and their treating healthcare practitioners in relation to goal planning?; and (4) What are the barriers and facilitators to effective goal planning in mental health settings? Two independent researchers will screen the articles, selecting literature that meets criteria. All literature, regardless of study design that involves adult participants, with a mental illness and reporting on goal planning will be considered for inclusion. Data will be extracted from all eligible articles regardless of study design and summarised in a table. Appropriate quality assessment and data synthesis methods will be determined based on included study designs. ETHICS AND DISSEMINATION: No ethics approval is required. The results will be disseminated through peer-reviewed publications and conference presentations. PROSPERO REGISTRATION NUMBER: CRD42020220595.

Subjective Experiences of Mental Health Crisis Care in Emergency Departments: A Narrative Review of the Qualitative Literature.

Mental health presentations to the emergency department (ED) have increased, and the emergency department has become the initial contact point for people in a mental health crisis. However, there is mounting evidence that the ED is not appropriate nor effective in responding to people in mental health crises. Insufficient attention has been paid to the subjective experience of people seeking support during a mental health crisis. This review aims to describe the qualitative literature involving the subjective experiences of people presenting to the ED during a mental health crisis. The method was guided by Arksey and O'Malley's framework for scoping studies and included keyword searches of PsycINFO, CINAHL, Medline and Embase. A narrative analysis, drawing on the visual tool of journey mapping, was applied to summarise the findings. Twenty-three studies were included. The findings represent the experience of accessing EDs, through to the impact of treatment. The review found points of opportunity that improve people's experiences and characteristics associated with negative experiences. The findings highlight the predominance and impact of negative experiences of the ED and the incongruence between the expectations of people presenting to the ED and the experience of treatment.

How much 'lived experience' is enough? Understanding mental health lived experience work from a management perspective.

Objective The aim of this study was to explore management understanding of the lived experience required for designated lived experience or peer roles within mental health. Method This qualitative study used semi-structured interviews and one focus group with 29 participants employed in diverse management roles from the public and not-for-profit health and community sector in Queensland, Australia. Results The findings indicate a lack of consensus in defining 'lived experience', including what lived experience is required to be eligible for designated roles. Although some participants were clear on what designated roles added to the workforce, uncertainty and attempts to avoid stigma led to some participants questioning the need for designated roles. Conclusion This study suggests the ongoing expansion of the lived experience workforce is affected by challenges in defining 'lived experience' as a requirement for designated roles and fears regarding stigmatised identities. What is known about the topic? In the mental health sector, opportunities and challenges exist in attempting to effectively incorporate the emerging lived experience or peer workforce. Research has highlighted the need for support from senior management, the need for role clarity and the risk of 'othering' for the lived experience workforce. What does this paper add? This paper responds to the gap in existing research on the experiences of management in defining and articulating their understanding of lived experience and potential impact of uncertainty and inconsistency in understanding for the lived experience workforce. What are the implications for practitioners? This study identifies the need to strengthen management understanding of lived experience to facilitate ongoing development of lived experience roles.

Participation in creative workshops supports mental health consumers to share their stories of recovery: A one-year qualitative follow-up study.

Participation in creative activities has been linked with positive outcomes for people with mental illness. This longitudinal qualitative study is a one-year follow-up of eight mental health consumers who participated in a series of creative workshops in Brisbane, Australia that aimed to increase participants' capacity and skills in sharing their stories of recovery with others. It also sought to understand successful factors of the creative workshops to inform future workshops. Semi-structured interviews gathered information regarding participants' memories of the workshops and how they had shared their stories with others over the preceding 12 months. Interpretative phenomenological analysis identified that participants' enjoyed being engaged in a range of creative mediums in a group setting; that peer mentor support was highly valued; and that participants' recovery stories had become more positive and were shared more often and openly with others. Overall, participation in the creative workshops had long-lasting benefits for participants with respect to improved confidence and understanding about their illness. Future creative workshops should consider the inclusion of peer mentors with lived experience as a support for participants to reauthor their recovery story.

Diary of a Mental Health Peer Worker: Findings From a Diary Study Into the Role of Peer Work in a Clinical Mental Health Setting.

Introduction: The importance of peer support workers in mental health care delivery has been extensively advocated for in mental health policy frameworks. However, there has been limited research examining the implementation of paid peer workers in clinical settings. This study explores the experience of paid peer support workers integrated within a clinically-operated community-based residential rehabilitation service for people diagnosed with a mental health disorder experiencing challenges living independently in the community. Methods: A general inductive approach was taken in the analysis of diaries completed by a newly employed peer workforce. These diaries focussed on what they viewed as significant interactions in fulfilling their role. Composite vignettes were generated to illustrate key themes. Findings: Thirty-six diaries were provided; these reported unplanned and spontaneously occurring interactions. Peer workers emphasized the importance of connecting with people while they were engaging in everyday activities as an opportunity for personal growth of the residents. The diaries also focussed on the peer workers' ability to connect and establish trust by sharing similar experiences with residents or family members. Peer workers also believed that they brought a different perspective than clinical staff and were able to refocus attention from clinical diagnoses and symptoms to other aspects of the resident's lives. Discussion: Peer support workers described their work as flexible, responsive, and adaptable to the resident's needs. They believed that their roles brought a different lens to interactions on the unit and fostered a more inclusive and personal way of working for the team. Conclusion: To ensure that peer workers can engage authentically with residents and family members, it is critical that the role and principles of peer work are valued and understood by all.