Creative approaches to mental health: a critical analysis of the mindfulness agenda in Sussex

Mindfulness is a packaged intervention with current popularity in East Sussex, and this study explores how it is embedded in mental health services, the processes of the gathering and presentation of evidence, how the experience of patients is organizationally shaped and the importance of indirect interventions. These forms of interventions are what has been termed ‘choice architecture’ by proponents of the ‘nudge agenda’, describing the way that decisions and behaviour are influenced by how the choices are presented or designed . I want to explore the feasibility of applying indirect interventions to mindfulness in order to increase take-up rates, evaluative mechanisms and follow-up support, based on the patient perspective. Mindfulness-based cognitive therapy (MBCT) was recommended by NICE in their guidelines in 2004, was brought fully into the mainstream and has now been specifically adapted for psychosis. My research is on the interaction between mindfulness as an innovative therapy, a marginalised group of people who experience psychosis, and the currently popular behavioural economics (nudge) agenda. The nudge agenda is being promoted on the basis of cost-effectiveness, the aptness of its ideology to the current political climate, and its evidence base in particular case studies. The use of creative indirect interventions such as nudge, ‘when carefully crafted and applied’, can be ‘a positive means of communication between physician and patient’

Creative interventions in mental health: a critical analysis of the mindfulness agenda in Sussex

Mindfulness-based Cognitive Therapy (MBCT) is a manualised psychosocial, group-based 8 week course specifically designed for people with a history of depression. This study responds to the huge growth in the credibility of MBCT as a therapeutic option in the NHS as well as a rise in the popularity and awareness of mindfulness-based interventions (MBIs). This study is based on semi-structured interviews (N=38) with stakeholders in the field of MBIs in Sussex, and an online survey of Sussex NHS Foundation Trust (SPFT) staff (N=203), as part of a wider collaborative ethnography embedded within the Trust. It contributes to existing literature on the efficacy of MBIs by exploring existing provision and follow-up support, reviewing the perceived benefits and costs of embedding MBCT into the health services. This study has a particular focus on participants of a recent SPFT Randomised Controlled Trial (RCT) ‘Mindfulness for Voices’ that investigated the efficacy of this therapy for people who hear distressing voices. This study brings together both the empirical and theoretical with its focus on mindfulness as a therapeutic technique that epitomises links between the mind, the body and society. This study draws on sociological work on embodiment and emotion in order to understand the experience of innovation as well as of MBIs – starting from the observation that many of those leading this area of research and implementation are also practising mindfulness. Furthermore, this study maps the theoretical shift from a narrow medical model of mental illness to one that characterises emotional health within a holistic and integrated paradigm, and which is influencing and shaping current practice. Key findings from this study are that MBIs, and MBCT in particular, can be beneficial to a diverse range of stakeholders within Sussex, including patient groups that were previously excluded from ‘talking cures’ such as those with a diagnosis of psychosis. Factors that influence the acceptability, visibility and utilisation of an innovation such as MBCT include the role of opinion leaders and champions in garnering support, as well as the degree to which expectations about the future of this intervention are managed. Drawing on sociologies of knowledge and innovation in the health services, the case is used to show the use of experiential knowledge alongside evidence in bringing about innovation. Clinicians also work to develop accounts of the ‘values’ at stake in MBIs; drawing on both evidence and experiential knowledge. The implementation of MBIs into the mainstream health service helps to illuminate some of these practices through being used to address conditions such as chronic pain and severe anxiety disorders which were hitherto seen as untreatable and characterised as ‘complex needs’, or medically unexplained symptoms (MUS) and which can be stigmatising

Presentation and attrition in complex pulmonary atresia

AbstractObjectives. This study summarized patterns of presentation and attrition in complex pulmonary atresia.Methods. We performed a retrospective review of age at presentation, referral source, pulmonary artery and collateral anatomy and surgical history of 218 patients from two institutions dealing with congenital heart disease throughout life.Results. Approximately 65% of pulmonary atresia appears in infancy, with 50% of patients severely symptomatic from cyanosis and 25% from heart failure. Compared with those presenting undiagnosed, patients referred secondarily for specialist management trend tobe older whe first seen, and cre must be taken when generalizing about the natural history of the condition from their survival experience. Overall actuarial survival, including the effects of operation, suggests that 60% (95% condifence limits [CL] 43 to 73) of patients presenting in infancy survice to their first birthday, 65% (95% CL to 51 to 74) those alive at 1 year old survive to the age of 10, and 16 (95% CL 5 to 31) of those alive at 10 years old survive to age 35.Conclusions. Novel surgical approaches habve generally been applied beyond infancy in patients selected by their survival through the period of greatest attrition for this disease. Unless successful application in symptomatic infants is demonstrated, we cannot assume that these serial and complicated operations will have a major impact on the outlook of most patients with complex pulmonary atresia

The ProActive trial protocol - a randomised controlled trial of the efficacy of a family-based, domiciliary intervention programme to increase physical activity among individuals at high risk of diabetes [ISRCTN61323766].

BACKGROUND: Increasing prevalence of obesity and disorders associated with sedentary living constitute a major global public health problem. While previous evaluations of interventions to increase physical activity have involved communities or individuals with established disease, less attention has been given to interventions for individuals at risk of disease. METHODS/DESIGN: ProActive aims to evaluate the efficacy of a theoretical, evidence- and family-based intervention programme to increase physical activity in a sedentary population, defined as being at-risk through having a parental family history of diabetes. Primary care diabetes or family history registers were used to recruit 365 individuals aged 30-50 years, screened for activity level. Participants were assigned by central randomisation to three intervention programmes: brief written advice (comparison group), or a psychologically based behavioural change programme, delivered either by telephone (distance group) or face-to-face in the family home over one year. The protocol-driven intervention programme is delivered by trained facilitators, and aims to support increases in physical activity through the introduction and facilitation of a range of self-regulatory skills (e.g. goal setting). The primary outcome is daytime energy expenditure and its ratio to resting energy expenditure, measured at baseline and one year using individually calibrated heart rate monitoring. Secondary measures include self-report of individual and family activity, psychological mediators of behaviour change, physiological and biochemical correlates, acceptability, and costs, measured at baseline, six months and one year. The primary intention to treat analysis will compare groups at one-year post randomisation. Estimation of the impact on diabetes incidence will be modelled using data from a parallel ten-year cohort study using similar measures. DISCUSSION: ProActive is the first efficacy trial of an intervention programme to promote physical activity in a defined high-risk group accessible through primary care. The intervention programme is based on psychological theory and evidence; it introduces and facilitates the use of self-regulatory skills to support behaviour change and maintenance. The trial addresses a range of methodological weaknesses in the field by careful specification and quality assurance of the intervention programme, precise characterisation of participants, year-long follow-up and objective measurement of physical activity. Due to report in 2005, ProActive will provide estimates of the extent to which this approach could assist at-risk groups who could benefit from changes in behaviours affecting health, and inform future pragmatic trials

National Income and Income Inequality, Family Affluence and Life Satisfaction Among 13 year Old Boys and Girls: A Multilevel Study in 35 Countries

Adolescence is a critical period where many patterns of health and health behaviour are formed. The objective of this study was to investigate cross-national variation in the relationship between family affluence and adolescent life satisfaction, and the impact of national income and income inequality on this relationship. Data from the 2006 Health Behaviour in School-aged Children: WHO collaborative Study (N = 58,352 across 35 countries) were analysed using multilevel linear and logistic regression analyses for outcome measures life satisfaction score and binary high/low life satisfaction. National income and income inequality were associated with aggregated life satisfaction score and prevalence of high life satisfaction. Within-country socioeconomic inequalities in life satisfaction existed even after adjustment for family structure. This relationship was curvilinear and varied cross-nationally. Socioeconomic inequalities were greatest in poor countries and in countries with unequal income distribution. GDP (PPP US$) and Gini did not explain between country variance in socioeconomic inequalities in life satisfaction. The existence of, and variation in, within-country socioeconomic inequalities in adolescent life satisfaction highlights the importance of identifying and addressing mediating factors during this life stage

Mindfulness, psychosis and the fine tightrope

This chapter explores the tension between perspectives of psychology, biology and spirituality in the context of mindfulness-based therapies for people experiencing psychosis and distressing voices, a population whose voices (and anomalous experiences) have often been marginalised. Mindfulness-based cognitive therapy (MBCT), is an intervention with current popularity in the Anglo-American world, and is in the process of being specifically adapted for psychosis. This paper explores the intersection between anomalous experiences and the diagnosis and treatment of psychosis, particularly following the work of Isabel Clarke who calls for a positive re-conceptualisation of vulnerability to unusual experiences, which she compares to the mainstream perspective of many psychiatric services. These issues are being explored in my current research alongside a study being run by Sussex NHS Foundation Trust called; Mindfulness-based therapy groups for distressing voices (M4V): A pragmatic randomised controlled trial(RCT) . This study is funded by the National Institute for Health Research (NIHR)(£183,000) and aims to evaluate the effectiveness of a new kind of „mindfulness-based group therapy‟ which seeks to help people learn new ways of managing and living with distressing voices. It is a fine tightrope to walk between seeing one‟s thoughts as just clouds moving across the sky of one‟s mind (a metaphor commonly used in MBCT), and realising an inter-connectivity and connection with a wider whole, whilst remaining grounded in day-to-day relations with other people. This is a line that we all have to tread. I am interested in the potential for mindfulness to be a new way of working with this psychotic and spiritual threshold, and the potential for it as a therapy to help people form therapeutic alliances and develop a more autonomous relationship with their own bodies and selves

'Nudge': the potential for application to mental health and well-being: Unpacking the evidence base behind this popular agenda, its stakeholders, and innovative directions for future research

This book explores the currently popular ‘Nudge Agenda’ in the field of Behavioural Economics. ‘Nudge’ is based on the idea that no choice is ever presented in a neutral way, that the behaviour of humans can be inconsistent and contradictory, and that psychological techniques can be used to influence this behaviour. This book explores how and why nudge is being employed by the UK government at this time. The evidence base for its effectiveness in public health promotion is assessed, and the political necessity for a clear cut answer explored. It explores ethical issues arising with the theoretical components of these suggestions, and issues relating to the unequal application of the agenda to more vulnerable groups. A wider public health, social policy research and financial argument is also made. This paper draws conclusions about potential lessons to be learned from the gaps in current publications, and makes specific recommendations for evidence-based application and future research in this dynamic and changing area. The analysis will be of use to students of social policy, mental health and behavioural economics, as well as policy makers themselves