'Thinking outside the box: alternatives to standard inpatient mental health care' by Amber Jarvis

c/o The Mental Elf on 'X' I came across a blog post by Amber Jarvis:

Thinking outside the box: alternatives to standard inpatient mental health care

Amber's post considers a study by:

Griffiths, J. L., Baldwin, H., Vasikaran, J., Jarvis, R., Pillutla, R., Saunders, K. R., … & Johnson, S. (2025). Alternative approaches to standard inpatient mental health care: development of a typology of service models. International Journal of Mental Health Systems, 19(1), 1-13: https://pubmed.ncbi.nlm.nih.gov/40247283/

At an online meeting this evening, near the close the discussion loosened and alighted on AI. The ability of AI to summarise a large text file, a *.pdf and create discrete web HTML pages. The racial bias 'built-in' by human coders, reflected in outputs; that point to structural racism. 

Finding this paper on X, boxes are the bread and butter of Hodges' model. Not just thinking outside a box, or inside one, but several and with a final twist - to follow. Amber begins:

'Inpatient mental health care involves staying in a hospital or specialised facility to receive intensive, round-the-clock support for serious mental health needs (Staniszewska et al., 2019). Whereas acute inpatient services typically respond to immediate crises, longer-term wards support individuals with more complex needs and a higher level of ongoing risk.

Inpatient services are a core component of our mental health system — whether someone stays for a night, weeks, or even several years. However, inpatient care has recently come under growing scrutiny – and for good reason.'

A Community Mental Health Nurse since 1985, my in-patient experience is a tad misty, but not misty-eyed. As the wards: psychogeriatrics, long-stay, female acute admission were simultaneously challenging, rewarding - in the sense of being able to make a positive difference, changing what were institutionalised practices, no personal clothes, lockers, tea urn, no banking, few visitors (admission wards excepted). It was all very quotidian: check the bath book. Then tell, confirm, assure the patient, 'yes!'. It is your bath day. I've posted previously about critical mental health. You do (should?) quickly learn you are part of a system, a machine; and the distinction between person- patient-centred and service-centred care. The need to do my 'general' quickly emerged too. 

As ever, two words, across Amber's post and Griffith et al's title, stand out; 'map' and 'typology'. I must revisit and post about:

Macduff C. (2007). Typologies in nursing: a review of the literature. Nurse researcher, 14(2), 40–50. https://doi.org/10.7748/nr2007.01.14.2.40.c6020

Part-time work since 2020, in two adult CMHTs and a recovery team, has provided an update. The first as COVID emerged, was a bit of a shock in terms of diagnoses, caseness, the proximity to the law and forensic psychiatry, thresholds for referral, changes to mental health law (that were now more practical) and the management of patient's finances. 

So, to return to last night's brief online discussion, the observation of how racism is ongoing, brought up the fact of racism being structural and institutional (Dean & Thorpe, 2022). The change needed is an intergenerational break, which doesn't bear thinking about. The National HEALTH Service faces the same challenges in the shift to prevention, and addressing racism. Where is the workforce, going to come from, to help recovery, health and related literacies (media, emotional, financial)?

It is easy in boxes like Hodges' model (and others) to be idealistic. Ideally as I learned of Community Psychiatric Nurses being recruited, six of us, we all should have asked:

What is the plan?

What is the model of care?

What characterises 'care in the community'?

How do we prevent relapse, readmission?

Is there a 'halfway house'*?

We did, to an extent. There was great enthusiasm, motivation, idealism, co-ordination, collaboration  (Tyrer & Gelder, 1990) and leadership. 'We' had an association,^ and a journal. Back then the Royal College of Psychiatry produced a report on CPNs. Is there a message in this? Progress was and has been made, but the promise has not been delivered. With care in the community having regressed, an incomplete 'project'.

I will read more and revise this post, or more likely add another: with less 'history' ...

Individual

|

      INTERPERSONAL    :     SCIENCES               

HUMANISTIC  --------------------------------------  MECHANISTIC      

 SOCIOLOGY  :    POLITICAL 

|

Group

Model of Care	Model of care
Model of Care Care in Community Children - Schools - Education	Model of care 'Care Leavers'

*'Cross-settings' in Griffith et al.

^https://www.unitetheunion.org/what-we-do/unite-in-your-sector/health-sector/mental-health-nurses-association

Lorraine T Dean, Roland J Thorpe, What Structural Racism Is (or Is Not) and How to Measure It: Clarity for Public Health and Medical Researchers, American Journal of Epidemiology, Volume 191, Issue 9, September 2022, Pages 1521–1526, https://doi.org/10.1093/aje/kwac112

Tyrer P, Gelder M. The future of community psychiatric nursing: some research findings. Psychiatric Bulletin. 1990;14(9):550-551. doi:10.1192/pb.14.9.550

ii 'Thinking outside the box ...'

iii 'Thinking outside the box ...'

See also: 'institution' : 'racism' : 'typology' : 'map' : 'Forensic'

Book: Waiting to Be Arrested at Night

'I' - 'Individual' 'self' 'person'
a Would-Be Citizen

|

     INTERPERSONAL    :     SCIENCES               

HUMANISTIC --------------------------------------  MECHANISTIC      

SOCIOLOGY  :   POLITICAL 

|

dyad/couple family GROUP community culture
society population

Let all the people go and be who they can be to the benefit of each other

Tahir Hamut Izgil, Joshua L. Freeman (Translator)

Waiting to Be Arrested at Night
A Uyghur Poet's Memoir of China's Genocide

My source:
Yang, Y. A city under siege, Books. Life&Arts, FTWeekend, 9-10 September 2023, p.11.

Book cover: Penguin Books.

Mother?

individual
| 

 INTERPERSONAL : SCIENCES

humanistic ----------------------------------------------- mechanistic

SOCIOLOGY : POLITICAL

|

group

Give Up!	Give Up!
GIVE UP!	GIVE UP![You will!]

 

... your baby

 

My source: BBC Radio 4 

https://www.bbc.co.uk/news/uk-wales-57251782

Book review: ii Critical Mental Health Nursing: observations from the inside

Following on from Part i

In fairly recent studies at Lancaster University (2014-2016) autoethnography was notable by its presence. Given the importance of reflection in mental health theory and practice and the self-reflective approach of autoethnography and its qualitative, objective - subjective focus it is not surprising that several chapters adopt autoethnography. From Wikipedia:

Autoethnography differs from ethnography, a social research method employed by anthropologists and sociologists, in that autoethnography embraces and foregrounds the researcher's subjectivity rather than attempting to limit it, as in empirical research. While ethnography tends to be understood as a qualitative method in the social sciences that describes human social phenomena based on fieldwork, autoethnographers are themselves the primary participant/subject of the research in the process of writing personal stories and narratives. Autoethnography "as a form of ethnography," Ellis (2004) writes, is "part auto or self and part ethno or culture" (p. 31) and "something different from both of them, greater than its parts" (p. 32). In other words, as Ellingson and Ellis (2008) put it, "whether we call a work an autoethnography or an ethnography depends as much on the claims made by authors as anything else" (p. 449). https://en.wikipedia.org/wiki/Autoethnography

Gadsby's chapter 1 "Nursing violence, nursing violence" starts in this research vein. The title is quite an affront to many nurses. These two words do not mix, violence an abomination, antithetical and counter to all that 'nursing' should represent. This is in part why 'care scandals' are so shocking given the vulnerability of those affected and impacted for years to come. Gadsby points straight to the challenge:

"I do not like to say, as  some critics do, that reforms of mental health nursing is impossible; I think of good moments and good colleagues and feel it betrays them. I worry that this chapter will feel that way too." p.14.

There no better learning than when your assumptions are turned on their head; you are forced and can see for that instant the other side of the coin, even if, like an optical illusion it snaps-back. Gadsby presents three conversations. Inevitably in conversations there is the verbatim transcript (as if recorded audio-video), then there is our account of what was said and then what is recorded on paper or in the electronic record. Jonathan Gadsby points out that he was selective in his accounts and this is a prime judgement for mental health nurses. What is pertinent is looking at this from the patient's^* perspective. The complexity of his (John) mind was likely to be interpreted as illness, and this presages coercion and loss of his future.

"He took care of their (mhn's) mental state. I have come to believe that this is common; our simplistic stories leave our service users having to channel their real lives into fairly useless false binaries and sanitised, dishonest versions of their actual experiences, in order to gain or retain any power. p.15.

Rereading the section for this review on 'John' I was surprised it was so short. Reading this was like revisiting several clients of old. 'Old' bears specific mention as some of the situations used in the book, are quite dated - John refers back to 2004. The lessons and insights are still salutary. In exploring 'violence' the chapter starts by explaining debt violence. It is 'social inclusion' in practice (and an appeal to and for justice?) to see this, considering austerity and campaigns stressing the links (ties) between financial vulnerability and mental illness. On 'nursing violence', Gadsby discusses three areas: a few bad apples, 'genre violence' and the world is violent.

My ward experience as a charge nurse was brief 1982-1985, so I have been removed from the 'frontline' of mh services. Without being ageist I've been twice-removed in working with older adults. Since becoming a Community Psychiatric Nurse in 1985 if the narrative had been wholly positive: the funding, policy, education ... what would the experience for patients, staff and carers? If mhn could ask itself the miracle question of solution focussed therapy, what would our history, present, future be like?

Some of Gadsby's points are shocking and reveal the experiential fact of the few bad apples. There is an overlap here with Nikki Marfleet, a speaker at this past week's Health and Justice Summit. @TheLRH stressed the need for assuring that both good and difficult conversations with staff take place. As a student nurse and newly qualified nurse you recall wondering who you were to work with next shift: and not just management-wise. It was not necessarily the 'who' you would be working with, as the 'attitude'. This is a fact of life within many occupations, but in mental health the impact can be literally that. Nikki noted that the difficult conversations can be positive as well as challenging behaviours and attitudes as the desired team culture is built. The bottom line though on the tenor of the difficult conversation is can you, do you, really want to keep that bad apple? I have seen situations were the approach was, if continued, provocative and not deescalating. We have all met them, the individuals, who, even after giving them the benefit of doubt, you are left wondering why are you still here (and somewhere quiet you tell them).

The Recovery Star (Triangle updated) saw Gadsby as a life-coach being an early adopter. 'Recovery' features markedly in the book. The figure and description of Smith's work - 'The structural model of genre'. There are practical insights here, especially for new student nurse. As Gadsby writes of, "trying to change the system from within.", I smiled ruefully. I used to feel sympathy, oops sorry! empathy, for the patients on the Long Stay ward [37A] and others. I had a distinct sense that as a new group of students started, the patients rolled their eyes (and not in some oculargyric crisis*) but out of their patience (yes, the patient's patience) being tested to maximum. As the students set-to to change the behaviour pattern of some key individuals (were they viewed as such?). They slept late, smoked too much, might palm - pretend to swallow their medication, they spent too much time on their beds, their personal hygiene was poor. They were certainly 'key' as subjects for our student assessments; yes, me too.

In my reading, Gadsby alludes to the rationale by which people are attracted to mental health nursing (p.22). Perhaps stories have a formative role to play? [At risk of a slight digression] Recently I've been really surprised by the psychological and medical content of TV programmes I was watching from age 10-11. Star Trek's "Dagger of the Mind" for example; UFO with "Sub-Smash" and "The Man Who Came Back" and many others (in contrast to many peers at the time I only saw "One Flew Over the Cuckoo's Nest" in the 80s).

If that is (was) about 'future nurses' Gadbsby refers to Burstow's institutional ethnography, and one "notion of how psychiatry is perpetually on the cusp of a humane scientific breakthrough" (p.23) Critically, this is not Star Trek, but how Burstow explains the violence of the present in terms of time. Gadsby teaches psychiatrists too and this book has lessons for the whole 'multidisciplinary team'. He points out how models of care as we deliberate on 'caring about' versus 'caring for'.

Hodges' model is a 'health career' model, not a model of care, but it can help facilitate all forms of care.

Gadsby and other authors here identify many polarities: care and control, advocacy and correction. In the late 1970s and 1980s we were not just nurses, but 'patient advocate'. The nurse literature and rising profile of human rights called this into question. In mental health though for some formal meetings you may struggle to have an independent advocate present (is that time playing with us again - temporal violence of however many hours, days, months?).

individual

|

INTERPERSONAL : SCIENCES

humanistic ----------------------------------------------- mechanistic

SOCIOLOGY : POLITICAL

|

group

The person - individual - self
"proximal experiences"	"over the power horizon" the STATE "distal power"

Gadsby correctly anticipates that this account of experiences, thought and conclusions may be read as damning. The book as whole provokes a real double-bind. The violence is a reality (yes, look at the World, p.25) and so often violence is the news^#. So too, is the compassion to effect (constant) change; even as the medication is administered in the sacrifice zones (pp.27-28).

Gadsby writes: "We frequently work within models that fail to make sense of the connections between inner and outer experience, past, present and future..." (p.25).

Yes, don't we just (whether accidentally or not).

Difficult as this is, this text is vital reading for CMHNs, nurse students and a much wider audience.

More to follow - with possible additions^# here...

^*Seriously, I am grateful to say I have not witnessed this in my 41 year career.


Parts iii

Part iv

Bull, P., Gadsby, J., Williams, S. (Eds.) (2018) Critical Mental Health Nursing: observations from the inside, Monmouth: PCCS Books. ISBN 9781910919408

Book review: i Critical Mental Health Nursing: observations from the inside

If the book's title does not suggest the challenge to come then perhaps the editor's "Our apology" just might.

The editors declare the limitations of their apology as mental health nurses (mhn) given the precariousness of life, the environmental situation, the power of global corporations and how the industrial-military complex can also affect and define the role and work of mental health nurses. It is clear, that for example, the past decade (at least) of mental health service provision and development has been impacted by political and socioeconomic trends. The reduced number of mental health beds; the subsequent phenomena of out of area referrals (that also redefine 'area'). This past month, commentators have pointed to the lack of a work-force plan that should precede NHS Long Term Plan.

From the start the vocabulary here is rings of 'anti-psychiatry' and seeks, if not redress, then redesign of formal mental health services. Anyone putting the book down at this stage would be doing themselves, patients, carers, health and social care and their own learning a great disservice. Clearly, it is not only that existing services are reductionist, invalidating, self-serving, drug-pushing and re-traumatising; but the editors stress it is how they are all too often experienced.


As a mental health nurse the introduction and apology gets to heart of the matter, if not the mind. All of what mhn's do is tinged with coercion; whether with people on locked wards or those in their own home. The list of what mental health nurses are party to is a long one and makes difficult reading: the detention and restraint of people and administration of antipsychotic depot medications. The profession hides behind the ethics of acting in a person's 'best interests'. The negative impact of this experience is not just limited to a vulnerable minority who are in most marked emotional distress, but others as the book attests. If this suggests a caveat, there are several, as I hope this review across several posts will reveal. That custard cream shared with a patient (person, householder, tenant, citizen...) in their home will never taste the same. So, more on that to follow and not just to address any sense of trivialisation, but the many caveats that apply.

The editor's frame their apology outlining the basis for mhn: as a profession, a university degree, codes of conduct and accountability. p.viii As a 'profession in our own right' the critical thinking we espouse (yes - here too) and are supposed to exercise has failed to question and counter the increase in detention and the assault on mental health services themselves. At one stage I believed there was some coherence to mental health policy development, but if it is there now - it is intangible in its quality. MHS have not developed progressively as might have been anticipated if not exactly predicted. As a new Community Psychiatric Nurse in 1985 I am now a 'Community Mental Health Nurse', what else might my colleagues and I have become? At the end of the day we may longer return to the hospital (Winwick, Eaves Lane, Ribbleton - all gone), but what are we returning to when we go back to the office, the base? There is an office move in this book; and the final chapter considers the profession's very title.

The editor's apology does not just set the scene, it places mhn and all practitioners on the stage - front and center. This RMN (SRN) (to be ageist for a moment) is all too aware that despite all the talk about the need for integrated, holistic, person-centred care they are, more often than not, still lacking. I've come to see these as 'legacy issues', but that is another 'book'?

The book itself has 260 pages in total. The cover of my (softback - as above) is a pleasing contemporary design. The mainly white cover is already a suffering grey as it's been on numerous trips. Thirteen chapters follow the apology and an introduction. There are notes on the editors and contributors. The print is an excellent size and the overall format easy on the eye. Even if lightly edited, the editors have done a good job as the chapters cohere. Two indices cover names and subjects and are sufficient. So with chapter 1 beckoning I was all-eyes and ready page turning...

Thanks to PCCS Books for my review copy.

Part ii

Part iii

Part iv

Bull, P., Gadsby, J., Williams, S. (Eds.) (2018) Critical Mental Health Nursing: observations from the inside, Monmouth: PCCS Books. ISBN 9781910919408