Brighton Journal of Research in Health Sciences

Supporting Research in the School of Health Sciences


How does exercise affect people who experience extreme states of mind and what impact might this have on mental health nursing practice?


People whose experiences are classified by the medical model as schizophrenia, bipolar affective disorder or psychosis, die 16-25 years sooner on average than people with no mental health diagnosis (Department of Health (DH) 2011b). It is three times more probable they will suffer premature death (DH 2011c), with increased risk of several physical illnesses, such as heart disease, diabetes, respiratory disease and infections, and obesity (DH 2006; DH 2011b,c; Rethink 2013 a, b, c; DH 2014a; NICE 2014b).
The prescribing of anti-psychotic medication may lead to weight gain, sometimes up to 5-6 kg in the first 2 months (Foley and Morley 2011; Rethink 2013a). This may be due to several factors, including a more sedentary lifestyle and a related lack of exercise. The World Health Organisation (WHO 2015) and The Department of Health (2014b) in their policy ‘everybody active every day’ stipulate that adults should be aiming to be active on a daily basis. However 27 million adults in England are not active enough to benefit their health (DH 2012), and the Secretary of State is calling for the NHS to make the promotion of active lifestyles central to all healthcare professionals work (DH 2012).

This literature review topic was chosen because in practice as a student nurse I have thought there is inadequate emphasis placed on exercise and believe that service users would benefit from its inclusion in mental health services.

The phrase ‘extreme states of mind’ (May 2014), is used to describe people in receipt of biomedical diagnoses, such as schizophrenia, bipolar affective disorder, schizoaffective disorder and psychosis. The choice of a non-medical phrase may help in the shift from a medical to a more holistic view of the experiences of people, within which mental health difficulties are described in more compassionate, less stigmatizing ways (Carless and Douglas 2008a; Moncrieff 2009; Johnstone 2014).


In order to first identify the research question, substantial reading was necessary in the field of interest, namely exercise and mental health. A Boolean search was utilised in order to search most efficiently across a range of databases. From this, a few key interests emerged. These were women’s mental health in relation to exercise, the role of the service user voice in exercise, and exercise and serious mental health issues. As there exist a significant number of papers around depression, anxiety and exercise but little on serious mental health issues, my search was made more specific by setting the inclusion and exclusion criteria to only include papers concerning serious mental health issues.
A total of 15 papers emerged as significant. These were predominantly qualitative, with four quantitative and one descriptive study. A simplified thematic analysis was performed on the papers selected (Noblit and Hare 1988; Paterson et al 2001; Rice 2008; Aveyard 2014). Three themes emerged from the papers reviewed, which go some way towards answering the research question: the social, the psychological and the physiological effects of exercise.

Social Effects

The literature signified the importance of the social effects of exercise for people who experience extreme states of mind. The peer support and friendships gained from participation in exercise (Carless and Douglas 2008a, 2008b, 2012; Hodgson et al 2011; Klam et al 2006) appear as a substantial specificeffect, as does the routine and structure it brings to people’s lives (Klam et al 2006; Crone and Guy 2008; Carless and Douglas 2008b; Hodgson et al 2011; Ronngren et al 2014; Cullen and McCann 2015). Participants also identified that exercise positively affects their social roles and highlight the value of shared experience (Crone and Guy 2008; Carless and Douglas 2012; Hodgson et al 2011; Cullen and McCann 2015).

Peer Support and Friendship

Narrative inquiry seeks to find the meaning that people make of their experiences and what it means to be human. It is a creative process that can often bring about change for the participants through the process of re telling the story, narrative re-storying (Carless and Douglas 2008a). The theme of potential benefits through the development of peer support and friendship when exercising was present in several studies. The narrative inquiry work of Carless and Douglas (2008a, 2008b and 2012) hasstrong peer support and friendship themes, and a clear service user voice is heard throughout. These three studies aimed to look at how men experiencing extreme states of mind utilise narrative re-storying through exercise and sport (2008a), how they might receive social support through exercise (2008b) and the narratives of people using physical activity programmes within mental health services (2012). For some people who experience extreme states of mind, the social role that exercise provides is helpful. One participant from Carless and Douglas’s 2012 study typically described his life before engaging in sport as lacking in friends and this meant also he experienced feelings of isolation. This study has a strong service user voice, which makes the pertinence of the statements more compelling. The work of Hodgson et al (2011), supported by Crone and Guy (2008) and Cullen and McCann (2015) also illustrate the role of exercise in alleviating some of the isolation felt by service users through meeting new people in the community.

Psychological Effects

From a psychological perspective, the literature generally revealed how exercise may assist people who experience extreme states of mind to be more motivated, be more proud, confident, have greater self esteem, have fun and alleviate symptoms.


For some, participating in exercise or physical activity led to an increase in motivation to continue exercising (Fogarty and Happell 2005) and in others, exercise increased their desire to make healthy lifestyle changes, such as reducing the intake of fast foods (Klam et al 2006). Motivation can be difficult for people experiencing extreme states of mind, and whether this is because of the impact of medication on motivation or the lack of structure in their lives is unclear (Crone and Guy 2008). In a Norwegian study, Tetlie et al (2009) discussed a mandatory exercise programme in a forensic setting. Mental health professionals participated alongside patients and found this unique approach helped decrease power imbalances on the ward, promoting ‘likeness’. The effects that exercise has on increasing motivation for this population are diverse, although some people are enabled to exercise more (Fogarty and Happell 2005; Warren et al 2011). Nurses exercising with clients may also challenge stigma (Tetlie et al 2009), and this will be explored in more depth in the discussion chapter.


For some, exercise can also be fun and pleasurable, (Klam et al 2006; Crone and Guy 2008; Tetlie et al 2009; Cullen and McCann 2015). Humour in mental health is creatively prioritized by Klam et al (2006), with the incorporation of humour workshops into their ‘personal empowerment program’. In the weeks following this intervention clients were heard sharing jokes and they described how this helped them take life a little less seriously. The fun element was something that was shared between staff and patients in the study by Tetlie et al (2009), further breaking down the barriers between them.


Having fun and experiencing pleasure in life through exercise could also be a way of distracting oneself from the negative experiences of extreme states of mind. It may, according to Cullen and McCann (2015), be a useful tool for voice hearers, as the time spent concentrating on exercise is time spent not concentrating on voices. One participant defined this as ‘it takes you out of living in your mind’ (Cullen and McCann 2015, 61).
Exercise may also counteract boredom, which is often an aspect of inpatient mental health services, and in the community is exacerbated through social isolation (Crone and Guy 2008; Hodgson et al 2011).

Confidence, Pride, Self Esteem, and Sense of Purpose

The effect of exercise on confidence, pride, self esteem and sense of purpose is reported in numerous studies (Crone and Guy 2008; Hodgson et al 2011; Cullen and McCann 2015). Confidence is crucial for participating in social activities (van Deurzen 2012), and self esteem is often interconnected with this (Crone and Guy 2008). In related terms, people who experience extreme states of mind have often lost their confidence (Carless and Douglas 2008a) and sense of purpose (Hodgson et al 2011), and exercise might be something that can help restore this.By extrapolation, the psychological effects of exercise might therefore influence how well an individual participates in society (Tetlie et al 2009) and vice versa (van Deurzen 2012). Peer support, routine and social role positively impact on people’s motivation to exercise, increasing their confidence, pride, self esteem and their ability to have fun.

Physical Affects

The majority of literature included in the review discusses the importance of maintaining good physical health for this population, especially given the negative impact medication and lifestyle can have on diabetes, weight, and the heart (DH 2006, 2011b).


Weight has been identified as a major issue in mental health difficulties (DH 2006; DH 2011c; Mental Health Foundation 2009; NICE 2011; Rethink 2013a, b; NHS 2014b; NICE 2015a). Disappointingly there was only one paper that measured weight loss as a result of exercise (Klam et al 2006). The study by Warren et al (2011) attempted to study weight loss in the USA but was flawed through a lack of accurate data recording, weight gain precipitated by meal vouchers and bias as a result of the involvement of pharmaceutical companies. Other studies have approached the issue but also failed to gain significant results as a consequence of not including diet and nutritional advice in conjunction with exercise (Schwee et al 2013).
Several qualitative studies found that people exercised in order to manage and control their weight. Interestingly, only one study directly found related weight gain and associated issues to the medication prescribed for extreme states of mind – namely second generation antipsychotics (Hodgson et al 2011). Again there are a majority of papers in this review who assert weight gain due to antipsychotic medication in their abstracts, yet only Hodgson et al (2011) reported empirical information on this.

Blood Pressure, Fasting Sugar Levels and Smoking

Klam et al (2006) described positive physical changes to blood pressure, fasting blood sugar levels, smoking and fitness among people with extreme states of mind in Canada. However, this is a descriptive paper and not generalizable. Whilst training for a 5K race, study participants increased their mean steps by 1445.33 over a 10 week period, which is an indicator of increased fitness (Warren et al 2011). Cullen and McCann (2015) highlight that exercise can make someone feel stronger and this motivates them to eat healthier when they can see their physical health improving. It is interesting that physical rather than psychological benefits of exercise were found to be most important to the participants in study by Bassilios et al (2014). This interview-based study of 45 people who use community mental health service around Melbourne, also highlight the importance of education surrounding the benefits of exercise. However, there remains a lack of quantitative evidence in this area. All of this highlights the urgent need to address the physical health of this population. Some studies have approached this issue but have failed to find significant results through poor planning, lack of validity and poor recording (Warren et al 2011; Usher et al 2012; Scheewe et al 2013).



The majority of the studies reviewed recommend that exercise is incorporated into daily mental health practice, which will require support from mental health staff. An important aspect of personal recovery highlighted, is personalised, individualised care. The significance of peer support was a key finding, as was staff exercising with service users.

The literature reflects the importance of exercise staff being highly skilled, especially in mental health. Although personal recovery frameworks advocate increased independence from mental health services, several studies recommended that mental health specific exercise support should be available for those that need it.

It is acknowledged that there are lower participation rates in exercise for women, and also recognised that the stories that women may tell about exercise may be markedly different from men’s accounts. From the literature reviewed, exercise culture can generally be viewed as a male-dominated and thus exercise provision may not be tailored to the needs and requirements of women. Much of exercise provision is based on performance, whereas women might be more interested in the relational outcomes that exercise might bring. This hints at women perhaps gaining more from the benefits of peer support in exercise, but adquate evidence to support this is not currently available.

The positive effects of exercise have been recognised in this review as similar to cohere with the four ontological realms of existentialism, notably the physical, social, spiritual and personal worlds of the individual. The importance of personal meaning and significance is a crucial goal of recovery, and mental health nurses and researchers need to explore this realm with their service users in the context of engagement with exercise.

The findings of the literature reviewed also highlight this, and also point to the benefits of peer support which may also impact on motivation and vice versa. Someone experiencing extreme states of mind might have fun when exercising, which might them lead them to feel more motivated, which in turn may inspire them to do more exercise, thus improving their health, weight and fitness. The literature thus emphasises findings emphasise the interconnected nature of human experiences and how exercise can potentially have an impact on all areas of life.

This review has highlighted the importance of the role of exercise in the process of recovery. This is a subjective process and has a different meaning for each individual, and so, in practice, the personal meaning of recovery emerges as important. Personal recovery models have outcomes differing significantly from clinical recovery, which refers to the reduction and absence of psychiatric symptoms. Personal recovery refers more to regaining social roles, building and consolidating relationships that bring meaning and value to life, and developing hope.

The literature and policy recommend that exercise should be included in mental health services, and specifically to be included in individual care plans. The DH (2012) ‘lets get moving’ pathway has brief interventions already designed, but these need tailoring to this population, which would require more research for it to be evidence based. Clearly, the inclusion of effective exercise in care plans it needs to be supported by mental health professionals.

The DH (2012) state that promotion of active lifestyles is a key role of all healthcare professionals, therefore mental health nurses need to support the promotion of exercise and its sustainment. Nurses also need to be equipped to educate their service users about exercise, know how to refer to other services and instigate practice development where necessary. Crone and Guy (2008) highlight the role of the mental health nurse as practice developers and one emerging suggestion is that they take a role in organising discounts with local sports facilities. For this to be implemented would require nurse education in exercise and a knowledge-base of how to drive practice developments themselves.

If exercise is promoted by mental health professionals and included in care plans it needs to be tailored to individual preferences. Mental health policy and guidelines promote the idea of individual care, especially in personal recovery frameworks. For exercise to be as effective as possible, service users need to be offered a choice of activities and programmes to suit their individual needs. This is especially pertinent for this population, every person’s experiences are unique and require tailored support both generally and specifically in exercise interventions.

The benefits of peer support in exercise, is a potentially interesting finding for future practice development and current guidance is to promote it in mental health services more generally. Peer support in this context is the mutual and reciprocal support provided by another person who has experienced extreme states of mind (Mental Health Foundation 2012). It appears to play a key role as one of the positive effects of exercise. NICE (2014) suggests the use of trained peer supporters in psychosis and schizophrenia and Rethink (2013c) also recommend the use of peers to aid personal recovery.

In practice as a student nurse, I have only met two peer support workers. As a future mental health practitioner I would like to be able to encourage service users to assume this role. It seems clear that they can help contribute directly in the recovery of others and themselves. However, Slade et al (2014) state that this needs to not be tokenistic, ensuring that suitable training and support for this role is in place. For the role of peer support workers to be prioritised in exercise provision, clearly more research is needed.

The review highlighted that in fact exercising with service users was something that increased motivation, reduced stigma and strengthened the therapeutic relationship. Nurses who have undertaken exercise alongside service users have been very positive about its impact, for the services users, themselves and in the case of inpatient services or recovery houses, on the unit as a whole (Happell et al 2012). If this initiative was more widely adopted, nursing staff would be exercising also, therefore taking care of their own physical health needs. However, exercise provision in mental health does demand skilled professionals who are also sensitive to the needs of people experiencing extreme states of mind.

The value of the research into the effects of exercise for people who experience extreme states of mind does not seem sufficient to influence evidence-based practice. Future research is needed in several areas, to include gender sensitivity; how exercise increases meaning in life; peer support, motivation; and service user-led research (Rose et al 2011). Importantly, there is a dearth of significant research included in this review concerning weight loss, which is a key to reducing the health risks that anti-psychotic medication poses. Medication is a contributing health risk of this population, and pharmaceutical companies have an ethical duty to produce medication with less damaging side effects (Bental 2004; Moncreiff 2009).


This review set out to look at the effects of exercise for people who experience extreme states of mind, and how these findings might impact on mental health nursing practice. There is a lack of research in this area, particularly for women, leading to deficiencies in related evidence-based nursing practice. However, the evidence available points to the positive social, psychological and physical effects of exercise.

The literature review recognises that exercise could be used to aid personal recovery, and that this might lead to a less stigmatised view of the individual and their relationship to wider society. The importance of service users being able to re-story their lives through social acceptable activities is highly significant and mental health nursing practice needs to embrace the importance of narrative in all areas of practice. Peer support is already recognised as a vital element of practice and this review recommends that it be explored further in relation to exercise and extreme states of mind. Nurses require education to assist their practice development in these contexts.

Amy Barlow, former Mental Health Nursing BSc(Hons) student


Aveyard, H. 2014. Doing a Literature Review in Health and Social Care. A Practical Guide. 3rd Ed. Maidenhead: Open University Press.

Bassilios, B., F. Judd and P. Pattison. 2014. Why don’t people diagnosed with schizophrenia spectrum disorder (SSDs) get enough exercise? Australian Psychiatry. 22(1): 71-77.

Bentall, R. P. 2004. Madness Explained: Psychosis and Human Nature. Harmondsworth: Penguin

Carless, D. and K. Douglas. 2008a. Narrative, identity and mental health: How men with serious mental illness re-story their lives through sport and exercise. Psychology of Sport and Exercise. 9: 576-594.

Carless, D and K. Douglas. 2008b. Social support for and through exercise and sport in a sample of men with serious mental illness. Issues in Mental Health Nursing. 29: 1179:1199.

Carless, D. and K. Douglas. 2012. The ethos of physical activity delivery in mental health: A narrative study of service user experiences. Issues in Mental Health Nursing. 33: 165-171.

Crone, D. and H. Guy. 2008. ‘I know it is only exercise, but it’s something that keeps me going’: A qualitative approach to understanding mental health service users’ experiences of sports therapy. International Journal of Mental Health Nursing. 17: 197-207.

Cullen C. and E. McCann. 2015. Exploring the role of physical activity for people diagnosed with serious mental illness in Ireland. Journal of Psychiatric and Mental Health Nursing. 22: 58-64.

Department of Health. 2006. Choosing Health: Supporting the Physical Health Needs of People with Severe Mental Illness. Accessed online 17/04/15.

Department of Health. 2011b. No health without Mental Health. Accessed online 11/12/2014.

Department of Health. 2011c. Atypical (Second Generation) Antipsychotics. Accessed online 01/04/15.

Department of Health. 2012. Lets Get Moving. Accessed 10/04/15.

Department of Health. 2014a. Closing the Gap: Priorities for Essential Change in Mental Health. Accessed 04/04/15.

Department of Health. 2014b. Moving More, Living More. Olympic and Paralympic. Games Legacy. Accessed online 20/03/15.

Fogarty, M. and B. Happell. 2005. Exploring the benefits of an exercise program for people with schizophrenia: A qualitative study. Issues in Mental Health Nursing. 26: 341-351.

Foley, D. and K. Morley. 2011. Systematic Review of Early Cardiometabolic Outcomes of the First Treated Episode of Psychosis. Archives of General Psychiatry. 68(6): 609- 616.

Happell, B., D. Scott, C. Platania-Phung and J. Nankivell. 2012. Nurses views on physical activity for people with serious mental illness. Mental Health and Physical Activity. 5: 4-12.

Hodgson, M., H. McCulloch, and K. Fox. 2011. The experiences of people with severe and enduring mental illness engaging in a physical activity programme integrated into the mental health service. Mental Health and Physical Activity. 4: 23-29.

Johnstone, L. 2014. A Straight Talking Guide to Psychiatric Diagnosis. Ross-on-Wye: PCCS Books.

Klam, J., M. McLay, and D. Grabke. 2006. Personal empowerment program: Addressing health concerns in people with schizophrenia. Journal of Psychosocial Nursing. 4(8): 20-28.

May, R. 2014. Blog. Accessed 11/12/2014.

Mental Health Foundation. 2009. Moving on Up. Accessed online 20/02/15.

Mental Health Foundation. 2012. Need2Know Briefing: Peer Support. Accessed 22/04/15.

Moncrieff, J. 2009. A Straight Talking Guide to Psychiatric Drugs. Ross-on Wye: PCCS Books.

National Health Service. 2014b. Valuing mental health equally with physical health or “Parity of Esteem”. Accessed online 11/04/15.
NICE. 2011. Preventing type 2 diabetes: population and community-level interventions. Accessed online 25/03/15.

NICE. 2014b. Psychosis and schizophrenia in adults: treatment and management. Accessed online 23/03/15.

NICE. 2015a. Psychosis and schizophrenia in adults. Quality statement 7: Promoting healthy eating, physical activity and smoking cessation. Accessed online 20/03/15.

Noblit, G. W. and R. D. Hare. 1988. Meta Ethnography: Synthesizing Qualitative Studies. Qualitative Research Methods Series. (11). London: Sage.

Paterson, B, S. Thorne, C. Canam, and C. Jillings. 2001. Metastudy of Qualitative Health Research. Thousand Oaks, CA: Sage Publications Inc.

Rethink. 2013a. The abandoned Illness: A report by the Schizophrenia Commission. Accessed online 10/04/14.

Rethink. 2013b. Lethal Discrimination. Accessed online 25/03/15

Rethink. 2013c. 100 ways to support recovery. Accessed online 07/04/15.

Rice, M. J. 2008. Evidence-based practice in psychiatric and mental health nursing: qualitative meta-synthesis. Journal of the American Psychiatric Nurses Association .14 (5): 382-5.

Ronngren, Y. M., A. Bjork, D. Haage and L. Kristuansen. 2014. LIFEHOPE:EU: Lifestyle and healthy outcome in physical education . Development of a lifestyle intervention program for people with severe mental illness. Journal of Psychiatric and Mental Health Nursing. 2: 924-930.

Rose, D., J. Evans, A. Sweeney, and T. Wykes. 2011. A model for developing outcome measures from the perspectives of mental health service users. International Review of Psychiatry. 23(1): 41–46.

Slade, M., M. Amering, M. Farkas, B. Hamilton, M. O’Hagan, G. Panther, R. Perkins, G. Shepherd, S. Tse, and R. Whitely. 2014. Uses and abuses of recovery: Implementing recovery-orientated practices in mental health systems. World Psychiatry. 13: 12-20.

Schwee, T. W., F. J. Backx, T. Takken et al. 2013. Exercise therapy improves mental and physical health in schizophrenia: A randomized controlled trial. Acta Psychiatric Scandinavia. 127: 464-473.

Tetlie, T., M. C. Heimesnes, and R. Almvik. 2009. Using exercise to treat patients with severe mental illness. Journal of Psychosocial Nursing. 47(2): 30-40.

Usher, K., T. Park, K. Foster and P. Buettner. 2012. A randomised control trial undertaken to test a nurse-led weight management and exercise intervention designed for people with serious mental illness who take second generation anti-psychotics. Journal of Advanced Nursing. 69 (7): 1539-1548.

van Deurzen, E. V. 2012. Existential Counselling and Psychotherapy in Practice. 3rd Ed. London: Sage.

van Deurzen-Smith, E. V. 1984. Existential therapy. In: Individual Therapy in Britain, edited by W. Dryden. London: Harper and Row.

Warren, K. R., P. Ball, S. Fieldman, F. Liu, R. P. McMahon, D. L. Kelly. 2011. Exercise program adherence using a 5 kilometer (5K) event as an achievable goal for people with schizophrenia. Biological Research for Nursing. 13(4): 383-390.

World Health Organisation. 2015. Physical Activity. Accessed online 03/03/15.


The Therapeutic Relationship and Issues of Power in Mental Health Nursing


Objectives: The therapeutic relationship is an important concept to mental health nurses, and many believe it to be the essence of nursing practice. However, the nurse patient relationship is one of imbalanced power. This study, completed as a BSc dissertation project, forms a scoping review, utilising a systematic approach, to examine the research on the relationship between power and the therapeutic relationship, with relevance to mental health nursing.

Methods: Literature was found online through texts available in the university library catalogue using a variety of search strategies. Literature was searched for on Cumulative Index to Nursing and Allied Health Literature, PsychINFO, ProQuest hospital collection, British Nursing Index and ScienceDirect. Additional articles were found using an ancestry and decendancy approach.

Results: Existing research gives collaborating evidence that there is a relationship between power and the therapeutic relationship. Not only is coercion related to negative evaluations of the therapeutic relationship, but the main way in which professionals influence patients to make healthy choices is through the therapeutic relationship. The context in which mental health nursing takes place also influences this relationship.

Conclusions: As there appears to be a relationship between power and the therapeutic relationship, nurses who identify with the concept of the therapeutic relationship would benefit from considering power as a pertinent theory. Nursing academics need to direct more resources towards researching power as there appears to be a dearth of nursing literature on this topic, particularly in the United Kingdom. Professionals may benefit from reflecting upon power as a concept that affects their reciprocal relationships with patients.


Although nursing is not generally considered a powerful profession (Barker 2009a), power dynamics frequently become apparent when thinking about relationships within nursing (Wilkinson and Miers 1999). Nowhere is this power more relevant than in the field of mental health, where legal powers are granted in order to detain persons who are deemed unwell and in need of assessment or treatment (The Stationary Office 2007).

Despite on-going criticism of psychiatry and its association with coercion, control and power (Szasz 2007; Foucault and Howard 1967; Goffman 1968), and continuing lack of evidence to demonstrate the effectiveness of compulsory treatment (Kisely and Campbell 2014), recent reports suggest coercive practices in the United Kingdom are increasing (Care Quality Commission 2015).

Resistance to the idea of coercion and control in psychiatry, may be found in the idea of empowerment, service user involvement and recovery, which have gained popularity in nursing literature (Barker 2001; Lloyd 2007; Caldwell et al. 2010) and in mental health policy (Department of Health 2011). However, the extent to which empowerment is possible, and its actual impact on service users true freedom and consent within a system that endorses detention and compliance, has been problematised (Grant 2009). This implies that it is important to think about empowerment in the context of the imbalanced power relationships that exist in mental health. That nurses endorse empowerment without appropriately considering the concept of power, may contribute towards ambiguity in terms of the approaches and definitions of empowerment within the nursing literature (Ryles 1999).

Perhaps the most pertinent theorist on power within mental health is Foucault due to his examination of madness (Foucault and Howard 1967), and of medical power (Foucault and Sheridan 1973). For Foucault, however, power is not something that can be held by certain groups or individuals, nor is it exclusive to intentional action. Power is essentially a positive force which permeates all levels of society and people are always simultaneously undergoing and exercising this power. Power, in this sense, is legitimised through knowledge ascertaining to what is considered true, or “discourse”. People are disciplined by discourses that work as normalising structures which guide people to understand the world and their bodies in certain ways (Foucault and Sheridan 1979). Although Foucault’s conceptualisation of power has been criticised as generalised to the extent that it loses any analytic force (McNay 1994), It also opens up ways of thinking about power differently, simultaneously avoiding specificity and reductionism.

The effects of power on relationships is pertinent to the role of mental health nurses as the “therapeutic relationship” is frequently cited as the core of nursing (Barker 2009b; Browne et al. 2012; Dziopa and Ahern 2008; O’Brien 1999).

The idea of therapeutic relationships were highlighted in nursing most notably by Peplau (1988, 16) who regarded nursing as ‘a significant, therapeutic, interpersonal process.’ This asserts the interpersonal nature of nursing, gives salience to nurse-patient relationships and highlights the need for these relationships to be therapeutic, promoting health and growth (Peplau 1988). Since Peplau, therapeutic relationships have been considered the core focus of mental health nursing (Barker 2009b; O’Brien 1999).

In order for a relationship to be therapeutic, though, it must function as more than an everyday relationship. It is a relationship in which the patient feels accepted as a person of worth, free to engage in self-expression without fear of rejection. Therapeutic relationships should involve communication that helps the nurse understand the needs and perceptions of the patient, enable the patient to learn about, or cope more effectively with their environment, and result in the reduction or resolution of the patients’ problems (Reynolds 2009).

The popularity of the therapeutic relationship in mental health nursing has not meant it is easily defined, however. In fact, it may have become more difficult to define now that it is tied into the mental health nurse’s identity (Browne et al. 2012). A literature review on what makes good quality therapeutic relationship identified nine overlapping constructs within the nurse-patient therapeutic relationship (See image 1), which require a complex interplay of skills dependent on the needs of both nurse and patient at a given time (Dziopa and Ahern 2008). Judicious use of power is implicated as one mechanism through which the development of a good quality therapeutic relationship is achieved, although the possibility of nurses abusing said power is also duly noted.

The impact of power on the therapeutic relationship has been alluded to (Dziopa and Ahern 2008; Wilkinson and Miers 1999). However, a review of the literature within this area may shed increasing insights into whether a relationship exists. This literature review, Inspired by my curiosity from practice, defines power as bi-directional, as something that can be used negatively (in coercion, compulsion, force and threat) and positively (through empowerment and legitimate authority or leadership). It also acknowledges that power can be overt (as in restraint or seclusion), or subtle (as in persuasion, approval and observation).

This literature review aims to highlight common themes in academic literature, and areas where more research is needed answering the question:

How does current primary research, with relevance to mental health nursing, explore issues of power within the therapeutic relationship?

There is potential for findings to help guide practice enabling nurses to be aware of the benefits and drawbacks of different facets of power and their use within the therapeutic relationship. It is also possible that the evidence found may confirm or deny whether these concepts are related.


The research question was developed during the process of preliminary searching around the concept of power and the therapeutic relationship. This allowed me to gain a sense of what published research existed on my chosen topic, leading to the development of a question that could be answered by the research available without becoming over or under saturated aiming for between 10 and 20 articles (Aveyard 2014).

As power can be conceptualised in different ways (Scott 2001), which may result in the exploration of different perspectives, it is important to use the appropriate terms associated with those perspectives in order to find a breadth of literature. Some synonyms of power have been mentioned in the introduction – yet preliminary searching revealed more. Authority represents the legitimate use of power while Control, coercion, restraint and restriction represent more invasive uses of power (Scott 2001). In addition, Agency and empowerment could be seen as positive elements of power whereas influence and leverage are more subtle forms of power (Wilkinson and Miers 1999). These synonyms of power were utilised as unique search terms in my preliminary search strategy.

Observations from preliminary searching demonstrated a dearth of specifically nursing literature within this topic indicating my search strategy would need to be broad. A systematic approach was adopted for the primary search strategy in order to gain a sense of the literature that already exists on this subject. Four separate search sectors were developed to ensure specificity to nursing, mental health, power and the therapeutic relationship respectively. These search sectors were combined using the Boolean logic AND so all results returned were relevant to all the search sectors (Boagy et al. 2013).

Within the search sectors, additional search operators were used informed by literature specific to performing a literature search (Aveyard 2014; Boagy et al. 2013; Jesson et al. 2011).

The extent that the search was restricted by the generic search sectors was then considered. “Therapeutic relationship” was considered as a limiting search term that may be described in other ways, for example, “therapeutic alliance” is another term that could be used. Further exploration uncovered “helping alliance” and “working alliance” but these proved to be more relevant to counselling and psychotherapy than nursing and including them did not expand results. The term “relationship” on its own was also considered, which caused the search to become too broad with an unmanageable amount of results (n=1108) from just one database.

The following databases were accessed as considered the most relevant to nursing psychiatry and sociology: CINAHL, PsychINFO, ProQuest hospital collection, British Nursing Index and Science Direct.

It was then necessary to develop inclusion and exclusion criteria (Table 1) in order to define the scope of the review (Aveyard 2014) and answer the research question: how does current primary research, with relevance mental health nursing, explore issues of power within the therapeutic relationship?

Inclusion and exclusion criteria

  • Only articles exploring power (and its synonyms) and the interpersonal relationship were included.
  • Only articles that were relevant to nursing were included. This included articles that were interdisciplinary in nature but excluded articles that were exclusive to other professions such as physicians.
  • Articles examining control and restraint as an intervention were excluded.
  • Only primary research was included.
  • Only research published after 2004 was included.
  • Only research available in English was included.
  • Research from all specialities of mental health was included.
  • Research from all countries was included.

As it is possible that searching through online databases alone may not find all relevant research, snowball sampling was used to accent this initial approach (Aveyard 2014).

When the full texts of the final articles were read, 9 did not meet inclusion criteria, leaving 10

Although similarities between findings were apparent from an early stage and fit into themes, to aid in presentation of the findings, articles were instead split into themes according to the approach used to gather data, rather than their findings. Critical analyses of each article took place using a research appraisal framework by Caldwell et al. (2011) as it is appropriate for both quantitative and qualitative research, both of which were included in the review. Critical appraisal of the articles were presented in the appropriate themes and the impact of each article was considered and synthesized for discussion.

The relationship between perceived coercion and evaluations of the therapeutic relationship

Four of the studies found through the literature search were Quantitative studies measuring service users’ perceptions of coercive practices alongside their evaluations of the therapeutic relationship to see if there is an association between these concepts. The following articles result in a fairly narrow conceptualisation of power as coercion, which, despite being often measured on a continuum, does not allow for positive conceptualisations of power. Also, a variety of measures are used to describe the therapeutic relationship resulting in some conceptual discrepancies within this area too. Despite this, the articles demonstrate that a relationship does exist between these concepts, which is significant (p<0.05) in three out of the four studies.

Stanhope et al. (2009) acknowledge case managers use of pressure in assertive community treatment of vulnerable populations in Pennsylvania, USA and seek to examine consumer’s perspectives in relation to these pressures through use of surveys delivered through face to face interviews. They recognise that introductions with consumers had to be negotiated through case managers which may result in social desirability bias.

Findings show a modest relationship between consumer-provider relationship, and perceived coercion with small effect size but no relationship between case manager’s utilisation of coercive strategies (pressure), and perceptions of coercion. It is noted, however, that case managers utilised almost exclusively low-end coercive strategies, such as verbal guidance (Neale and Rosenheck 2000). Higher perceived coercion was also related to shorter service contacts with a small effect size; more years spent in services with a medium effect size and negative service evaluation with medium to large effect size.

Sheehan and Burns (2011), from a complimentary perspective, seek to test a hypothesized association between the therapeutic relationship and the experience of coercion. A cross sectional cohort study was conducted for a consecutive sample of admissions to five acute hospitals in Oxford, England. Sheehan and Burns (2011) report a similar response rate (75%) to other articles exploring perceived coercion, but acknowledge that patients who decline to participate in research may have different views to those who did participate. How the population used in this study differs from a UK population is noted with consequences for generalizability.

Sheehan and Burns (2011) show that positive evaluations of therapeutic relationship with admitting clinician (12% identified as nurses), were significantly associated with low levels of perceived coercion; low levels of negative pressure and high levels of procedural justice, as measured by the AES. Perceived coercion was higher in participants who had been involuntarily admitted and logistic regression analysis showed the therapeutic relationship as an important factor, explaining 6% of the variance in perceived coercion. Just 21% of the variance was explained through the collected data indicating that other factors also come into play, including relationships with other staff members.

Furthermore, Theodoridou et al. (2012) use a similar approach in their study utilising a survey delivered through face to face interviews to measure the relationship between perceived coercion and the therapeutic relationship.

Theodoridou et al. (2012) show that higher levels of perceived coercion were consistently related to worse evaluations of the therapeutic relationship. Furthermore, involuntary admission, history of involuntary admission diagnosis of schizophrenia were all associated with higher AES scores.

These three articles present corroborating evidence to demonstrate that higher ratings of the therapeutic relationship are linked to lower perceptions of coercion in inpatient psychiatric populations across England (Sheehan and Burns 2011) and Switzerland (Theodoridou et al. 2012) and Assertive Community Treatment populations in the USA (Stanhope et al. 2009).

Wolfe et al. (2013), examine the relationship between coercion, motivation and therapeutic alliance in community-based drug and alcohol treatment in New South Wales, Australia. The researchers show that coercion was significantly related to external motivation and that external motivation was partially related to lower therapeutic alliance. However, no significant relationship was found between coercion and therapeutic relationship, apart from for the variable “openness”.

Patients perceptions of power and the therapeutic relationship

Further to the quantitative articles discussed previously, four articles found in the literature search were qualitative studies examining service users’ perspectives of power in various forms. While none of these studies sought to examine the therapeutic relationship, relationships with professionals emerge as an important concept from their results.

The following qualitative articles should help expand on the reductionist nature of quantitative research, enhancing understanding of how the variables of power and the Therapeutic relationship relate to each other in certain situations, as understood by service users, giving some sense of the complexity of this relationship.

Thogersen et al. (2010) aim to explore whether patients perceive Assertive Community Treatment (ACT) to be a coercive service due to ongoing academic debate about coercive aspects of the assertive provision of care. Participants were recruited, using staff as gatekeepers, from two newly formed ACT teams in Copenhagen, Denmark.

Themes were revalidated through agreement among other researchers and participants.

Lack of active participation in treatment processes and a poor alliance with case managers; not being recognised as an autonomous person and crossing the line and intruding on privacy, were recognised by Thogersen et al. (2010), as themes enhancing perceptions of coercion. On the other hand, a collaborative and mutually trusting relationship with case managers; commitment, perseverance and availability and a recognition of the need for social support and assistance with everyday activities were experiences that counteract perceptions of coercion. These themes can easily link coercion with the therapeutic relationship but also indicate other important factors, including time spent with patients; providing support; intrusion on privacy and case managers’ attitude demonstrated towards the patient. The study also demonstrates that different services invoke different experiences that relate to perceptions of coercion. Namely, ACT was considered coercive in that it was intimidating and overwhelming, whereas experiences of coercion in other services were related to lack of autonomy, lack of alliance with staff and lack of influence on treatment.

Tveiten et al. (2011) seek service users’ views and experiences of empowerment utilising data from focus group interviews. They define the concept of empowerment, relating it to concepts of advocacy, service user involvement and participation, stating that user participation allows transcendence of the power hierarchy inherent in psychiatry. The population is selected from two inpatient units in Norway, each with different acuity, but similar in relation to the services offered.

The three main themes included possibilities and presuppositions for participation, influence of the system on the empowerment process, and collaboration along a continuum of power between empowerment and powerlessness. Interesting to note for this review is that, in the possibilities and presuppositions theme, participants spoke about real acknowledgement, rather than acknowledgement as a formal claim.

Laugharne et al. (2012) aim to examine the experiences and attitudes of patients with psychosis in relation to factors that enhance or undermine trust, choice and power utilising face to face interviews. They acknowledge that, while participants found it difficult to engage with the concept of power, two overarching themes emerged. First that patients feel the need for a shifting balance of power that moves over time and is dynamic according to circumstances. Crucial to this shifting of power is improving patients’ understanding by providing them with information. Within this theme it is also suggested that threats of coercion and neglect disable patients.

Second, patients saw a trusting relationship as vital in their care. Trusting relationships are portrayed as going beyond the recognised expertise gained through training and experience, to include attributes and behaviours of patients as well as staff. The value of a personal touch was also stressed through aspects of kindness, hopefulness, friendliness, conversations about shared interests and personal disclosure from staff. There was contradictory evidence from some participants who suggest that they thought patient views should take precedence over scientific evidence and that relying on scientific knowledge was disempowering for patients.

Maguire et al. (2014) used a purposive sampling of 12 nurses and 12 patients from a forensic hospital in Australia to explore the practice of limit setting – a potentially coercive intervention, from both nurses and patients perspectives – in order to propose principles to guide practice. Limit setting is frequently used in forensic settings and it focuses upon setting boundaries in the therapeutic relationship and limiting or preventing disruptive behaviour.

Maguire et al. (2014) propose three themes. First, limit-setting is valued by patients as it sets boundaries around what are acceptable or unacceptable behaviours, promoting safety structure and control in the unit. This is also proposed as development of a therapeutic milieu.

Second, engaging patients in an empathic manner indicates that patients don’t find limit-setting as coercive in itself, but this is mediated by elements of the relationship in which patients feel understood, and understand why the limits have been set. Experiences of humiliation and disrespect contribute to coercive experiences, whereas experiences of limit-setting in a caring way did not damage the relationship or lead to negative outcomes.

Thirdly, the authoritative, rather than authoritarian style of limit setting suggests that, from a patient perspective, an authoritarian style is experienced as intimidating, aggressive and disrespectful and damages the therapeutic relationship. Conversely an authoritative style involves the nurse being knowledgeable about the patient and setting limits in a fair, consistent and respectful manner.

Nurses perceptions of power and the therapeutic relationship

Some qualitative articles found through the literature search considered power and the therapeutic relationship from a professional perspective. The professional perspectives explored appear to be more varied than the patient perspectives, some posing as a challenge to the use of power while others accepting the necessity of using power (or influence) to encourage healthy behaviours.

Maguire et al. (2014), explore nurses’ perceptions of limit setting, alongside previously mentioned patient perspectives, in forensic services. Many of the nursing perceptions are similar to patients’ perceptions, with nurses giving stories of observed poor practice resulting in aggressive responses or poor outcomes. However, separate to patients’ views, many nurses were uncomfortable with the term limit-setting as they believed it implied exerting control over patients as a coercive intervention.

Other nursing staff confirmed patient views, that limit setting was important for safety and maintenance of the therapeutic milieu. Having an understanding of the patient, and being fair, respectful and consistent was crucial to patients responding positively to limit-setting.

Cutcliffe and Happell (2009) highlight that interpersonal relationships, which are fundamental to nursing practice, are replete with issues of power. Despite discussions about empowerment being popular in the literature, Cutcliffe and Happell (2009) point out that there is a dearth of nursing literature examining power as it may be a difficult or uncomfortable subject for nurses. The study utilises examples from practice, with consideration for confidentiality, to illustrate health professionals’ use of power over consumers. Examples from practice enable naturalistic generalisations where readers gain insight through recognition of similarities in case study details and find descriptions that resonate with their own experiences.

Cutcliffe and Happell (2009) argue that these examples are tied to the use of invisible power through the dominant discourse of bio-psychiatry. They illuminate the recovery discourse as a viable alternative to this in which nurses can reconnect with Peplau’s theory of mental health nursing or, in other words, re-value the therapeutic relationship. However, this article paints an exclusively negative picture which taken alone may overemphasize the prevalence of the use of invisible power in current mental health practice.

In contrast, Gardner (2010) reports on a preliminary theory of how mental health nurses establish therapeutic relationships and maintain professional boundaries. The theory portrays the establishment of the therapeutic relationship as a gradual process, which begins with “therapeutic friendliness”, and develops through stages of “therapeutic engagement”, until a “therapeutic relationship” is developed and deepens over time.

Similar to Laugharne et al. (2012) who indicate that patients appreciate personal disclosure and conversations about shared interests, this study indicates that therapeutic engagement begins with a process of being friendly, which is not based on professional roles, but rather on getting to know each other. This is demonstrated to be particularly important in order to counteract the previous negative experiences many mental health clients have had in services before, supporting results suggesting that previous experiences of coercion might result in a higher likelihood of perceiving coercion in future (Laugharne et al. 2012; Theodoridou et al. 2012; Thogersen et al. 2010).

As a relationship progresses through the different levels of engagement it finally becomes a “Therapeutic Alliance” in which nurses can use “Therapeutic Leverage” as a form of influence that helps the client make the best decisions regarding their illness and health. It is important to recognise that “Therapeutic leverage” is different from coercion or manipulation, which would jeopardise the therapeutic relationship making it more difficult to manage. The level of influence a nurse has through their “therapeutic relationship” with a client can also be compromised when professional boundaries become blurred, resulting in confusion from the client as to whether the relationship is a friendship or a professional one, highlighting significant complexities within this framework.

Rugkåsa et al. (2014) highlight contemporary professional roles that are both empowering and controlling in light of recent changes in mental health where professionals utilise a range of “influencing behaviours”. The use of existing groups promoted discussion of professional perspectives on the use of “influencing behaviours”, to which real cases and existing relationships could be referred.

The quality of their relationships emerged as the central way in which professionals influenced patients, highlighting the need for trust within these relationships to be built over time. Honesty, curiosity, fairness, empathy, consistency and reliability were considered important to demonstrate within the therapeutic relationship, which in turn promoted engagement from patients. Providing something outside of patient expectations, such as going for coffee, or helping with practical tasks, helped to create reciprocal obligations, similar to findings by Laugharne et al. (2012) which suggest that patients also appreciate conversations about shared interests and staff personal disclosure, which is traditionally considered beyond professional boundaries. Emphasising the reciprocity of relationships, the authors describe “negotiating agreements” as another mechanism for influence. The final way of exerting influence was indicated as “asserting authority”, noting professionals’ power to compel, mainly through the use of the mental health act. This was seen as an inferior approach to others as, although it is a useful way of ensuring patient safety, it also had the potential to undermine relationships. The authors describe the difficulty navigating patients’ expectations about coercion that arrise from them having experienced coercion before. In fact, the very context of having the Mental Health Act to fall back on can be experienced as coercive in itself.

Strengths and limitations of study

As a novice researcher at undergraduate level, this review is hindered by inexperience and limitations placed by financial and time restrictions (Aveyard 2014). Publication bias may be an issue for this review as literature was only found on electronic databases which could be improved if efforts were made to search for grey literature (Polit and Beck 2014). Single author reviews might also increase the potential for subjectivity and bias, although I have consulted with my dissertation tutor, which will hopefully have helped limit my own biases where evident. I have also acknowledged my own views at the beginning of this research so that it would be evident to others if my own views did influence the results.

In contrast, I consider the broad approach to this research a strength, as it demonstrates the complexity of power relations instead of focusing on a single area. Although most articles are not exclusively relevant to nursing they acknowledge the interdisciplinary nature of working within mental health and nurses’ core role within the interdisciplinary team. Recommendations may be found as relevant to other professions working in settings alongside nurses but may also lack specificity to nursing.


Power is a complex phenomenon that may need to be broken down into other elements in order to be better understood and researched. This review was able to observe some of the current trends in research relevant to mental health nursing as to the way in which power is conceptualised.

The findings of this review mainly converge upon 4 areas: Legitimate use of power by professionals, the adverse impact of coercion, force and neglect, how are balance and reciprocity important to both power and the therapeutic relationship, and the influence of the system upon these perceptions. Mental health nurses are clearly in a position of power in comparison to service users and this review proposes that this is not inherently bad. There are examples of where professionals use their power legitimately and this is beneficial. This relies upon having a good Therapeutic relationship. However, the potential for coercion if this power is misused is apparent and perceptions of coercion are related to poor evaluations of the therapeutic relationship. Professionals should be aware that balance and reciprocity may be important concepts when thinking about building relationships in the context of unbalanced power relations and might also want to acknowledge that structural and environmental factors can influence how patients perceive actions as either legitimate or coercive.

There were only three articles exclusive to nursing (Gardner 2010; Maguire et al. 2014; Cutcliffe and Happell 2009) although two further articles had nurses involved as part of the research (Thogersen et al. 2010; Tveiten et al. 2011). The extent to which nurses can accurately reflect on and engage with the concept of power, when it has been indicated as something which they are uncomfortable discussing (Cutcliffe and Happell 2009), is highlighted by the lack of articles exclusive to nursing and the language used to signify power within those articles, such as leverage (Gardner 2010) and limit setting (Maguire et al. 2014).

It has been noted elsewhere that there is a dearth of nursing literature regarding coercion which is surprising considering that nurses are involved, directly and indirectly, in many coercive interventions (Galon and Wineman 2010). Although this review is exclusive to nursing, it was difficult to find exclusively nursing-related literature. Additionally, patients may be uncomfortable with the idea of power due to its negative connotations as noticed in certain studies exploring patients’ perspectives (Tveiten et al. 2011; Laugharne et al. 2012).

Although three studies were of UK origin (Rugkåsa et al. 2014; Laugharne et al. 2012; Sheehan and Burns 2011) none of these included a nurse in the research process. This is an important limitation as the unique culture of the UK may provide unique challenges and perspectives. Future research in the UK, including nurses in the process, would enable more specific recommendations to UK nurses in various settings and may highlight areas of power explicitly relevant to nursing. The EUNOMIA study highlights differences in coercive practices across European countries (Raboch et al. 2010), further cementing the difficulty in generalising this review between countries. Interestingly, the only centre where nurses order coercive measures more frequently than physicians was the United Kingdom (Raboch et al. 2010). The need for nurses to be involved in research about coercion in the UK, when they are the ones most frequently ordering it, is evident. However, as results in this review appear to conform across cultures and are supported by an article of international approach (Cutcliffe and Happell 2009), some implications of this review should not be discounted From a UK perspective.

Recommendations and implications for practice and research

Despite consensus in this review that many relationships might exist between power and the therapeutic relationship, further research is needed due to the quality of the current quantitative research and the tendency to focus on a single element of power: coercion. In regard to the relationship between perceived coercion and evaluations of the therapeutic relationship, longitudinal studies may help determine whether this is a causal relationship and experimental studies may be appropriate if an intervention specifically targeted at building a therapeutic relationship can be developed. Studies should continue to use face to face interviews to collect data for surveys as, although this is more time consuming, it results in a more complete data set and higher response rate. Directions in research to date appear to be interdisciplinary, reflecting the increasing interdisciplinary nature of mental health care. However, an increased nursing emphasis needs to be applied to research in order to relate findings specifically to nursing. The articles in this review were all written in what are considered high income countries (The World Bank Group 2015) reflecting the higher number of mental health professionals employed as a proportion of the population in these countries (World Health Organisation 2011).

The current research is difficult to generalise to UK culture and more research is needed in order to assess whether these findings can be generalizable across cultures, and whether unique cultures have unique differences. However, the homogenous nature of high income countries mean it would be more reasonable to generalise the findings of this review to the UK than to developing economies who do not have such a developed mental health workforce. Ethnographic studies involving participant observation may also be helpful in future in order to see if there is a difference between attitudes as gathered by interviews, and actions as seen through observation (Gobo 2011). Future research needs to make efforts to attempt to gain the views of individuals who for various reasons did not want to participate in current research. This will obviously pose practical and ethical challenges, although involving service users as part of the research team may provide new perspectives due to the potential for people to change their responses in relation to who is asking the questions. This also highlights the importance of increased nursing involvement in these research teams, which are currently overrepresented by medical staff.

Nurses may benefit from acknowledging power as a relevant concept within their practice, which appears to be strongly related to evaluations of the quality of the therapeutic relationship. Power may be an uncomfortable topic to reflect on as it may be seen as equating to coercion, but not all power is perceived as coercive and may be perceived legitimately. Relationships are clearly indicated as a factor in which perceptions of power may change. Some of the important aspects in these relationships to ensure they are empowering and not coercive are fairness, reciprocity, authenticity and a personal touch. Sharing of power involves the sharing of information and needs to be balanced appropriately throughout the relationship in order to avoid feelings of either coercion or neglect.

The need to reflect upon power has been demonstrated and there is potential for (ab)use of power to damage the therapeutic relationship. Coercion is also remembered by service users and impacts their perceptions of future encounters within services. The coercive context of mental health services may make service users more sensitive to issues of power and more prone to perceptions of coercion – and the threat of coercion through the mental health act itself may cause formation of therapeutic relationships to be more difficult. It may not be a coincidence that mental health nurses ascribe such value to the therapeutic relationship if you consider how difficult it is to build relationships in a culture where coercion is so prevalent. The influence of the system should not be ignored when thinking about power and current models of practice should be evaluated to determine their benefits and disadvantages in relation to the power relationships they can produce and, in turn, the effect this has on building trusting therapeutic relationships. In particular, the allocation of time should be considered as an important aspect of whether our relationships with service users are coercive or therapeutic.

Neil Molkenthin. Mental Health Nursing, BSc (Hons) Nursing Student


Aveyard, H. 2014. Doing a literature review in health and social care : a practical guide. Maidenhead: Open University Press.

Bale, R., J. Catty, H. Watt, N. Greenwood & T. Burns. 2006. Measures of the therapeutic relationship in severe psychotic illness: a comparison of two scales. Int J Soc Psychiatry 52 (3): 256-66.

Barker, P. 2001. The Tidal Model: developing an empowering, person-centred approach to recovery within psychiatric and mental health nursing. Journal of Psychiatric & Mental Health Nursing 8 (3): 233-240.

Barker, P.J. 2009a. The politics of caring. London: Hodder Arnold.

Barker, P.J. 2009b. Psychiatric and mental health nursing : the craft of caring. London: Hodder Arnold.

Bettany-Saltikov, J. 2012. How to do a systematic literature review in nursing : a step-by-step guide. Maidenhead: Open University Press.

Braun, V. & V. Clarke. 2006. Using thematic analysis in psychology. Qualitative Research in Psychology 3 (2): 77-101.

Browne, G., A. Cashin & I. Graham. 2012. The therapeutic relationship and Mental Health Nursing: it is time to articulate what we do! Journal of Psychiatric & Mental Health Nursing 19 (9): 839-843.

Busseri, M.A. & J.D. Tyler. 2003. Interchangeability of the Working Alliance Inventory and Working Alliance Inventory, Short Form. Psychological Assessment 15 (2): 193-197.

Cahill, J., G. Paley & G. Hardy. 2013. What do patients find helpful in psychotherapy? Implications for the therapeutic relationship in mental health nursing. Journal of Psychiatric & Mental Health Nursing 20 (9): 782-791.

Caldwell, B.A., M. Sclafani, M. Swarbrick & K. Piren. 2010. Psychiatric nursing practice & the recovery model of care. Journal of Psychosocial Nursing & Mental Health Services 48 (7): 42-48.

Caldwell, K., L. Henshaw & G. Taylor. 2011. Developing a framework for critiquing health research: an early evaluation. Nurse Educ Today 31 (8): e1-7.

Care Quality Commission. 2015. Mental Health Act Annual Report 2013/14. London: The Stationary Office.

Clark-Carter, D. 2010. Quantitative psychological research : the complete student’s companion. Hove: Psychology Press.

Cutcliffe, J. & B. Happell. 2009. Psychiatry, mental health nurses, and invisible power: Exploring a perturbed relationship within contemporary mental health care. Int J Ment Health Nurs 18 (2): 116-25.

Dancey, C.P. & J. Reidy. 2011. Statistics without maths for psychology. Harlow: Prentice Hall.

Department of Health. 2011. No health without mental health : a cross-government mental health outcomes strategy for people of all ages. Norwich: The Stationary Office.

Dziopa, F. & K. Ahern. 2008. What Makes a Quality Therapeutic Relationship in Psychiatric/Mental Health Nursing: A Review of the Research Literature. . The Internet Journal of Advanced Nursing Practice. 10 (1).

Edwards, P., R. Cooper, I. Roberts & C. Frost. 2005. Meta-analysis of randomised trials of monetary incentives and response to mailed questionnaires. Journal of Epidemiology and Community Health 59 (11): 987-999.

Elliott, R. & M.M. Wexler. 1994. Measuring the impact of sessions in process€xperiential therapy of depression: The Session Impacts Scale. Journal of Counseling Psychology 41 (2): 166-174.

Farrelly, P. 2013. Choosing the right method for a quantitative study… fourth article of a series. British Journal of School Nursing 8 (1): 42-44.

Foucault, M. & R. Howard. 1967. Madness and civilization: A history of insanity in the age of reason; Translated from the French by Richard Howard. . London: Tavistock Publications.

Foucault, M. & A. Sheridan. 1973. The birth of the clinic. An archaeology of medical perception … Translated … by A. M. Sheridan Smith. London: Tavistock Publications.

Foucault, M. & A. Sheridan. 1979. Discipline and punish : the birth of the prison. Harmondsworth: Penguin.

Galon, P.A. & N.M. Wineman. 2010. Coercion and Procedural Justice in Psychiatric Care: State of the Science and Implications for Nursing. Archives of Psychiatric Nursing 24 (5): 307-316.

Gardner, A. 2010. Therapeutic friendliness and the development of therapeutic leverage by mental health nurses in community rehabilitation settings. Contemp Nurse 34 (2): 140-8.

Gardner, W., S.K. Hoge, N. Bennett, L.H. Roth, C.W. Lidz, J. Monahan & E.P. Mulvey. 1993. Two scales for measuring patients’ perceptions for coercion during mental hospital admission. Behavioral Sciences & the Law 11 (3): 307-321.

Gobo, G. 2004. Sampling, Representativeness and Generalizability. In: Qualitative research practice. Edited by SEALE, C., G. GOBO, J. GUBRIUM & D. SILVERMAN. London: SAGE.

Gobo, G. 2011. Ethnography. In: Qualitative research : issues of theory, method and practice. Edited by SILVERMAN, D. London: SAGE.

Goffman, E. 1968. Asylums: essays on the social situation of mental patients and other inmates. Harmondsworth: Penguin.

Grant, A. 2009. Freedom and consent. In: Psychiatric and mental health nursing : the craft of caring. Edited by BARKER, P.J. London: Hodder Arnold.

Healy, D.M.R.C.P. 2009. Psychiatric drugs explained. Edinburgh: Churchill Livingstone.

Horvath, A.O. & L.S. Greenberg. 1989. Development and validation of the Working Alliance Inventory. Journal of Counseling Psychology 36 (2): 223-233.

Kisely, S. & L. Campbell. 2014. Compulsory community and involuntary outpatient treatment for people with severe mental disorders. . Cochrane Database of Systematic Reviews 2014, (12).

Laugharne, R., S. Priebe, R. McCabe, N. Garland & D. Clifford. 2012. Trust, choice and power in mental health care: Experiences of patients with psychosis. International Journal of Social Psychiatry 58 (5): 496-504.

Lloyd, M. 2007. Empowerment in the interpersonal field: discourses of acute mental health nurses. Journal of Psychiatric & Mental Health Nursing 14 (5): 485-494.

Maguire, T., M. Daffern & T. Martin. 2014. Exploring nurses’ and patients’ perspectives of limit setting in a forensic mental health setting. Int J Ment Health Nurs 23 (2): 153-60.

McCabe, R. & S. Priebe. 2003. Are therapeutic relationships in psychiatry explained by patients’ symptoms? Factors influencing patient ratings. European Psychiatry 18 (5): 220-225.

McNay, L. 1994. Foucault : a critical introduction. Cambridge: Polity Press.

Neale, M.S. & R.A. Rosenheck. 2000. Therapeutic limit setting in an assertive community treatment program. Psychiatr Serv 51 (4): 499-505.

O’Brien, A.J. 1999. Negotiating the relationship: mental health nurses’ perceptions of their practice. The Australian and New Zealand journal of mental health nursing 8 (4): 153-161.

Penny, K.I. & I. Atkinson. 2012. Approaches for dealing with missing data in health care studies. Journal of Clinical Nursing 21 (19/20): 2722-2729.

Peplau, H.E. 1988. Interpersonal relations in nursing : a conceptual frame of reference for psychodynamic nursing. Basingstoke: Macmillan.

Polit, D.F. & C.T. Beck. 2014. Essentials of nursing research : appraising evidence for nursing practice. London: Lippincott Williams & Wilkins.

Raboch, J., L. Kališová, A. Nawka, E. Kitzlerová, G. Onchev, A. Karastergiou, L. Magliano, A. Dembinskas, A. Kiejna, F. Torres-Gonzales, L. Kjellin, S. Priebe & T.W. Kallert. 2010. Use of Coercive Measures During Involuntary Hospitalization: Findings From Ten European Countries. Psychiatric Services 61 (10): 1012-1017.

Reynolds, B. 2009. Developing therapeutic one-to-one relationships. In: Psychiatric and mental health nursing : the craft of caring. Edited by BARKER, P.J. London: Hodder Arnold.

Royal Collage of Nursing. 2013b. Databases [Online Webpage]. London: Royal Collage of Nursing. Availableat: [Accessed 15/04/2015].

Rugkåsa, J., K. Canvin, J. Sinclair, A. Sulman & T. Burns. 2014. Trust, Deals and Authority: Community Mental Health Professionals’ Experiences of Influencing Reluctant Patients. Community Mental Health Journal 50 (8): 886-895.

Ryles, S.M. 1999. A concept analysis of empowerment: its relationship to mental health nursing. Journal of Advanced Nursing 29 (3): 600-607.

Selya, A.S., J.S. Rose, L.C. Dierker, D. Hedeker & R.J. Mermelstein. 2012. A Practical Guide to Calculating Cohen’s f(2), a Measure of Local Effect Size, from PROC MIXED. Frontiers in Psychology 3: 111.

Sheehan, K.A. & T. Burns. 2011. Perceived coercion and the therapeutic relationship: a neglected association? Psychiatr Serv 62 (5): 471-6.

Stanhope, V., S. Marcus & P. Solomon. 2009. The impact of coercion on services from the perspective of mental health care consumers with co-occurring disorders. Psychiatr Serv 60 (2): 183-8.

Stiles, W.B., S. Reynolds, G.E. Hardy, A. Rees, M. Barkham & D.A. Shapiro. 1994. Evaluation and description of psychotherapy sessions by clients using the Session Evaluation Questionnaire and the Session Impacts Scale. Journal of Counseling Psychology 41 (2): 175-185.

Swartz, M.S., H.R. Wagner, J.W. Swanson, V.A. Hiday & B.J. Burns. 2002. The perceived coerciveness of involuntary outpatient commitment: findings from an experimental study. J Am Acad Psychiatry Law 30 (2): 207-17.

Szasz, T. 2007. Coercion as cure : a critical history of psychiatry. New Brunswick, N.J. London: Transaction Publishers.

The Stationary Office. 2007. Mental Health Act 2007. London: The Stationary Office.

The World Bank Group. 2015. World Bank list of economies [Online Webpage]. Washington: The World Bank Group. Availableat: [Accessed 28/02/2015].

Theodoridou, A., F. Schlatter, V. Ajdacic, W. Rössler & M. Jäger. 2012. Therapeutic relationship in the context of perceived coercion in a psychiatric population. Psychiatry Research 200 (2): 939-944.

Thogersen, M.H., B. Morthorst & M. Nordentoft. 2010. Perceptions of coercion in the community: a qualitative study of patients in a Danish assertive community treatment team. Psychiatr Q 81 (1): 35-47.

Tveiten, S., M. Haukland & F.R. Onstad. 2011. “The Patient’s Voice-Empowerment in a Psychiatric Context”. Nordic Journal of Nursing Research 31 (3): 20-24.

Wilkinson, G. & M. Miers. 1999. Power and nursing practice. Basingstoke: Macmillan.

Wilkinson, S. 2011. Interviews and Focus Groups. In: Qualitative research : issues of theory, method and practice. Edited by SILVERMAN, D. London: SAGE.

Wolfe, S., F. Kay-Lambkin, J. Bowman & S. Childs. 2013. To enforce or engage: The relationship between coercion, treatment motivation and therapeutic alliance within community-based drug and alcohol clients. Addictive Behaviors 38 (5): 2187-2195.

World Health Organisation. 2011. Mental Health Atlas [Online pdf]. Geneva: World Health Organisation. Availableat: [Accessed 28/02/2015].



From lived experience to poststructural voice: Some implications for the use of autoethnography in mental health research.

Podcast lecture for MSc Social Work students, University of Utah given by Dr. Alec Grant, Reader in Mental Health


Seeking Sense in Mental Health

Mission Statement

We are a group of mental health nursing students aiming to create a therapeutic network to support students and professionals in practice.

We intend to provide a forum for open discussion and debate over practical and ethical issues relating to mental health theory, practice and service delivery.

Our network is intended to be multi-disciplinary and is open to all who work, study or simply have an interest or experience in the mental health field.

We appear to be at a time of great changes in the medical profession (Beasley, 2011; Lee & Fawcett, 2012) and nursing needs to find its own professional identity to develop and embrace those changes (Beasley, 2011; Clarke, 2012; Lee & Fawcett, 2012). However there appear to be conflicts within the very role of nursing. Advocacy, considered to be fundamental to nursing practice (MacDonald, 2006), is included as an essential quality of nurses in the Nursing and Midwifery Council (NMC) code (NMC, 2008) yet policy, in the shape of mental health legislation focus on risk management (Department of Health (DH), 2005), demands that mental health nurses be complicit in the denial of liberty and enforced treatment of some of those in their care (Pilgrim, 2005; Szmuckler & Applebaum, 2001).

The Royal College of Nursing (RCN) and the King’s Fund both suggest that nursing morale is at an all-time low (Royal College of Nursing (RCN), 2015; Independent, 2015). Seeking Sense in Mental Health (SSiMH) aims to focus on auditing morale levels of students in placement and attempt to find ways to address issues arising from workplace stress, consider questions over ethical or practical aspects of treatment and raise awareness of alternative or complementary perspectives.

SSiMH has a practical and intellectual purpose that aims to support and inform professionals, students and service users alike. One focus within the network involves bringing the process of mindfulness to our groups, encouraging participants to use the practice to benefit both their personal and working lives whilst potentially also offering positive experiences for service users, their carers and families (Beddoe and Murphy, 2004). Our interactions with clients carry myriad layers of our own mental clutter and one way of developing a ‘clutter free’ communication is to have awareness of possible countertransference. Scheick (2010) suggests that this awareness can be achieved through mindfulness.

The aim of mindfulness is to slow the rapid and stressful stream of thoughts that constantly flow through our minds. Coming to a point of acceptance that we are in the present, not dwelling in the past or worrying about the future, and stilling the mind brings great calmness and an inner peace. When we are at our most relaxed and creative, we are in alpha brain wave mode. Stress is reported to deplete the alpha wave functionality of our brains while meditative practices such as yoga, Tai Chi and mindfulness enhance it (Miller, 2011).

Psychiatric drugs are associated with a variety of unpleasant and potentially life-threatening side-effects (Boseley, 2003; Boseley, 2005: Charatan, 2005) yet medication remains the dominant form of treatment for mental health problems (Moncrieff, 2009). The availability of alternative treatments such as psychological talking therapies is geographically inconsistent and access to them often involves long waiting times (DH, 2014).

We hope to encourage discussion and evaluation of the merits of complementary and alternative treatments. We have already started to develop links with service user groups and organisations such as the Hearing Voices Network who offer differing perspectives on mental health provision. We intend to invite speakers to share their visions of the future of psychiatric service provision and run workshops which will enable us to consider alternative perspectives on approaches to treatment and support. We recently held the first of these sessions, a well-attended Gestalt Art Therapy practical event which investigated emotional responses to visual imagery.

We have a facebook page, or follows us on twitter @SSiMH_Network and the SSiMH website is under construction. We welcome comments, questions and suggestions from students, service users, carers, professionals and anyone else who may also be seeking sense in the mental health field.

Nik Holland, Zoe Hughes, Robyn-Jayne Crofton, Laura Johnstone, Chantelle Maduemezia, Sasha Marshall, Imogen Sotos-Castello and Graeme Wetherill Mental Health Nursing BSc (Hons) students


Beasley, C. 2011. The heart of nursing: past, present and future, British Journal of Nursing 20(22) 1407.

Beddoe, A.E, S.O Murphy (2004) Does mindfulness decrease stress and foster empathy among nursing students? The Journal of Nursing Education 2004, 43[7] 305-312. Available at: Accessed 10/02/2015.

Boseley, S. 2003. Drugs for depressed children banned. The Guardian. Available at: Accessed 04/01/15.

Boseley, S. 2005. Drugs ‘can trigger suicide in adults’. The Guardian. Available at: accessed 04/01/15.

Charatan, F. (2005) Study finds that new antipsychotics offer few benefits over traditional drugs’ British Medical Journal volume 331 p. 717.

Clarke, P. N. 2012. Discipline-Specific Knowledge: Time for Clarity, Nursing Science Quarterly 25(2) 149-150.

Department of Health (2005) Government response to the Report of the Joint Committee on the Draft Mental Health Bill 2004. London: Department of Health.

Department of Health (2014) Closing the Gap: Priorities for essential change in mental health. London: Department of Health.

The Independent (2015) NHS hospitals flatlining: Staff morale falls to new low after Coalition ‘bashing’ Available at: Accessed 16/02/15.

Lee, R. C. and J. Fawcett. 2012. The influence of the Metaparadigm of Nursing on Professional Identity Development among RN-BSN Students, Nursing Science Quarterly 26(1) 96-98. Available at Accessed 16/02/15.

MacDonald, H. 2006. Relational ethics and advocacy in nursing: literature review, Journal of Advanced Nursing 57(2) 119-126.

Miller, A. (2011) ​Exercises to Achieve Alpha Brain Waves. Available at: Accessed 10/02/2015

Moncrieff, J. (2009) Deconstructing psychiatric drug treatment’. In: Mental Health Still Matters, edited by J. Reynolds, R. Muston, T. Heller, J. Leach, M. McCormick, J. Wallcraft, and M. Walsh. Milton Keynes, The Open University.

NMC (2008) The code: Standards of conduct, performance and ethics for nurses and midwives. London: NMC.

Pilgrim, D. (2005) Key Concepts in Mental Health. London: Sage.

RCN (2015) ‘Nursing workforce morale at all-time low’ Available at: Accessed 16/02/15.

Scheick, D.M. (2010) Developing Self-Aware Mindfulness to Manage Countertransference in the Nurse-Client Relationship; An Evaluation and Developmental Study. The Journal of Professional Nursing 27[2] 114 – 123. Available at: Accessed 10/02/2015

Szmuckler, G. and Applebaum, P. (2001) ‘Treatment pressures, coercion and compulsion’. In: Textbook of Community Psychiatry, edited by G. Thornicroft and G. Szmuckler. Oxford: Oxford University Press.


Therapeutic Photography


There is accumulated evidence that art through many mediums has an intrinsic value in modern healthcare provision (Staricoff 2004). McNiff (1981) endorses the position that all art forms are valid and a variety of creative expression that stimulates all the senses is therapeutically beneficial. Warren (2007) argues that such meaningful avenues of expression build resilience, support recovery and are unlimited in therapeutic value. He argues that individuals can be empowered through the creative process in the creation of an image, word, sound or movement which gives an individual affirmation to the ontologically secure position that ‘I exist. I have meaning’.

Photography provides vast opportunities within mental health care for therapeutic interventions (Bach 2001; Glover-Graf and Miller 2006; Smith and Grant 2014; Weiser 2014 accessed 1 June 2014). Throughout this essay I will explore the value of photography as a public art form and its benefits within mental health care. I will draw evidence from both literature, personal experience and practice, in using photography as a therapeutic tool.

Photography as public art

Photos are everywhere; with the digitalisation of the 21st Century there has been a change in in the accessibility of photography. Previous to the appearance of modern technology, photography was a highly technical medium that was not accessible to all. Nowadays advances in technology mean that photography is much more widely accessible; rather than requiring expensive equipment and a darkroom, taking pictures only requires a disposable camera or mobile phone. The tradition of family photo albums has largely been replaced through social network sites and cyber storage, and the rise in accessibility of the Internet means that visual images captured through photography can be shared with wider audiences (PhotoVoice accessed 1 June 2014).

Photography in healthcare

The use of photography in healthcare can be dated back to the work of Dr Hugh Diamond who used photography with psychiatric patients in the mid-nineteenth century, and by the mid-twentieth century ‘phototherapy’ was used for both physical and psychological health care (Wheeler 2012). The works of Jo Spence (Fig.1), further strengthened the impact of photography as a therapeutic intervention. Her controversial works in the 1980s used photography as a medium to explore and make sense of her own experience in healthcare whilst undergoing cancer treatment (Dennett and Spence accessed 1 June 2014).

NaishImg1Figure 1. Jo Spence and Terry Dennett, The Picture of Health? 1982-86

The formal use of ‘Phototherapy’, which aims to improve people’s social and empathic sensitivity, requires some minimal training (Smith and Grant 2014; Weiser 1999; Weiser accessed June 2014). However the use of less specific therapeutic interventions in healthcare using photography requires no formalised training. The benefits of photography within healthcare are extensive due to the variety of processes involved, such as taking and processing photos, looking at old personal photos and exploring photographic images taken by others. The ensuing therapeutic advantages include providing support for individuals to: explore self identity, better understand and explore the social context behind images, aid memory, use as a tool to communicate and creatively express emotions through creativity (Bach 2001; Fryrear 1980; Glover-Graf and Miller 2006; Weiser accessed 1 June 2014; Wheeler 2012).

The use of photography as a therapeutic tool within mental health care holds particular value in the exploration of self and self-identity. A significant factor amongst high proportions of individuals who have experienced mental health issues is a ‘negative self–image’ is (Glover-Graf and Miller 2006). The use of photography in exploring self-image can support an individual to develop self-knowledge and create a positive self-image, which in turn impacts on confidence and self-esteem (Weiser 2014 at). In addition, using photography to explore self-identity induces conversations that allow an individual to control how they tell their story and validates their own experience (Bach 2001, PhotoVoice accessed 1 June 2014).

Photography can provide a transformative narrative to enable people experiencing mental distress to engage in dialogue and explore meanings and their significance (PhotoVoice accessed 1 June 2014) – to, in short enable people to make sense of their worlds (Martin 1999). Furthermore, photography can provide a medium to communicate and express what cannot be verbalised. For people who are experiencing mental distress this can be of particular value. This is particularly well demonstrated through John Keedy’s (2012, accessed 1 June 2014) ‘it’s hardly noticeable’ exhibition (Fig.2). Keedy uses photography to express experiences of, in his terms, ‘unspecified general anxiety’. His images provide an insight into this experience.

naish-img2Figure 2.  John Keedy ‘It’s Hardly Noticeable’ VIII, 2012

My use of photography in the Allsorts youth project

I have used photography in my own life as a therapeutic intervention in a number of settings and have observed the benefits of photography in others. For the past nine years I have worked both on a voluntary and employed basis at Allsorts youth project, based in Brighton. Allsorts supports young people aged 13 to 26 who identify as lesbian, gay, bisexual, transgender or unsure of their sexuality or gender orientation (LGBTU). Although identifying as LGBTU is not a mental health issue, people who do so are at greater risk and are more likely to experience mental health issues due to discrimination in the context of a long history of LGBTU oppression within social structures (Mental Health Foundation accessed 2 June 2014; NHS choice accessed 1 June 2014).

Allsorts, places great importance on the use of art in its mental health and well-being programmes, through media such as music, creative writing and visual arts. Photography has been used extensively within Allsorts to affirm identity, build confidence, raise self-esteem, and challenge social constructs and normative notions such as heteronormativity cisgender bias. In addition to the individual therapeutic benefits of using photography as an art form, the images produced are very often published and used in campaigns to raise awareness of the LGBTU issues in the wider community. This adds a further dimension to the therapeutic benefit of photography for the young people involved, in the way that it helps them build on their confidence and self-esteem.

Identity is a key issue for LGBTU young people who attend Allsorts as this often conflicts with heteronormative and cisgendered biased social structures, causing oppression and isolation (Butler 1993; Mayberry 2013). Inevitably, an LGBTU identity can become the focus of a person’s identification. The social power of heterosexual cisgenderd identity is normalised, and LGBTB people are ‘othered’ through social discourses, for example ‘the gay doctor’ (Beasley 2005). In order to support young people to recognise that they do not have to be solely defined by their sexual orientation or gender identity, Allsorts worked collaboratively with Star Peers to produce a photo campaign that recognised that LGBTU people were defined by more than their sexuality or gender (Fig 3, accessed 1 June 2014). The project used self-portraits and words with the phrase ‘I am…’ that defined individuals in terms other than that of their LGBT status.

naish-img3Figure 3. Allsorts & StarPeers ‘I am…’ 2013

Whilst working with young people and taking photos of their portraits using words to define themselves, I noticed that they initially struggled to find phrases or words that were separate from their LGBTU identity. This offered opportunities for open dialogue with young people around their identity and what it meant to them.

Further, this was the basis of a further project using photography, to explore with young people what Brighton meant to them. During the ‘what Brighton means to me’ (photos unpublished) project, I supported young people in creating photos that told a story about their relationship with Brighton as their home. Throughout this project I observed the multifaceted benefits of photography as an art form. The process of taking the photos provided young people with an opportunity to support and encourage each other, strengthening their relationships. Whereas other art forms such as drawing or painting can initially be quite daunting for people who feel they have no creative ability, photography essentially simply requires capturing images. Them realising that they were able to create images through the use of cameras this boosted the confidence of the young people involved in creative expression. Furthermore the opportunity to explore Brighton rather than staying at the youth centre created a fun and enjoyable experience and the dialogue of telling their story initiated a vast range of conversational subjects. For some, Brighton meant excitement, community and home. For others, Brighton was place of safety and sanctuary in its diversity and acceptance of the LGBT community. Through sharing their experiencesof the images they created, the young people were able to add context to their identity and those experiences.
A significant photography project produced by Allsorts was ‘HumanBeing:BeingHuman’, (Allsorts 2014, accessed 1 June 2014) in which young Transgender people used photography with autoethnographical text to tell their own stories, in an exploration of self-identity. Whilst I was not directly involved in the production of this project it did serve as a tool to have a meaningful discussion with a young person through exploration of the photos.

During one of Allsorts drop-in sessions I was looking through HumanBeing:BeingHuman’ ‘with a transgendered female, Emma aged 19 (pseudonym used to protect confidentiality). Emma commented on one of the ‘non-recognisable self-portraits’, saying that she wished she could be ‘non-recognisable’. I asked Emma to expand on this, which gave her opportunity to tell her story. Emma has only recently joined Allsorts and had not disclosed her gender identity anyone outside of the facility. While Allsorts provided her with a safe space in which she could wear makeup, be known as ‘Emma’ and referred to with the pronoun ‘she’, outside of Allsorts Emma is known by her birth name and referred to as male.

We had a long discussion exploring Emma’s two conflicting identities. This discussion in itself was therapeutic for her, as she had not had the opportunity to discuss this before. In addition Emma said that HumanBeing:BeingHuman gave her hope, insight into the fact that she is not alone and a determination to pursue her identified gender as a female. This experience highlighted to me the importance of sharing stories and experiences in order to support individuals in the wider community. Photography provides a medium through which oppressed minority groups such as LGBTU communities become visible:

Without the visual identity we have no community, no support network, no movement. Making ourselves visible is a continual process.
(Joan Biren 1983, Cited in Muholi 2010, 5)

Photography, heteronormativity and me

I personally enjoy photography; I find the process of capturing an image that creates meaning for me and induces an emotion or meaning for others therapeutic. I realised the significance of my own therapeutic relationship with photography through creating visual images for a photo essay earlier this year. Identifying as a lesbian and having active involvement in challenging heteronormative concepts in the last decade, I chose to write my essay on challenging stigma within mental healthcare through the experience of the LGBT community. It wasn’t until I created the photo ‘Bottled Up’ (fig.4) (Naish 2014) that I realised I had not been able to express the impact that hetronormative discourses within society had had and continues to have on me as an individual. Until that moment the notion that my sexual orientation had been oppressed, was a metaphorical concept that had no validity other than what was ‘felt’ by me. In producing the image it created a ‘concrete’ visual expression, which I have not been able to verbalise previously.

naish-img4Figure 4. Jaime Naish ‘Bottled up’ 2014

My use of photography in nursing placements

My experience in using photography is predominantly related to my work with LGBTU young people. However I have also used photography in my nursing placements, including while working in the community mental health team when my mentor and I were supporting a 52-year-old man, John (pseudonym to protect confidentiality) who had a diagnosis of generalized anxiety disorder. One of John’s coping strategies wass to visualise places where he felt safe and secure if he becomes anxious in public. However recently he had been finding it difficult to retain such an image in his mind. We discussed both what the causes of this may be and the value of a number of different techniques to support his visualization, one of which was to use photographs of images that invoked feelings of safety, to support his visualization.
When I next saw John he reported that he had had an experience of becoming anxious whilst out shopping. He had used visualisation and mindfulness as a coping strategy to get himself home, although he still found it difficult to manage his anxiety. However he did remember the suggestion of looking at photographs and picked up an old family holiday album. John was surprised to realise he had spent an hour looking through photos, enjoying and laughing at memories of him and his brothers having fun on the beach. This served as a valuable distraction tool for him. Furthermore he showed me a photo of himself and his brothers as children on the beach, which he had saved onto his phone, and said ‘this is my favorite photo – it takes me to a place where I have no worries’.


Photography provides vast opportunities within mental health care for therapeutic interventions. Its overall significance should be understood is in the context of how using the arts generally can benefit healthcare, since Other media such as literature, movement and dance, music and myriad other art forms also have significant value in both the mental and physical Healthcare arena. In nursing there is the opportunity to utilise art to add another, counterbalancing dimension to the dominant medical model. Photography is a relatively cheap and simple to use medium in which health care users can explore self-identity, and express emotions through visual creativity.

Jaime Naish, Mental Health Nursing BSc (Hons) student


Allsorts Youth Project. 2014. Being:Being Human’ Photographic work Exploring Life as Trans* Youth.[Online] available from [accessed 01/06/14]

Allsorts & StarPeer. 2013 ‘I am’ [online] available from [accessed 01/06/14]

Bach, H. (2001). The place of the photograph in visual narrative research. Afterimage, 29(3), 7. [Online] available from: [accessed 01/06/14].

Beasley,C. 2005. Gender and sexuality: critical theories, critical thinkers. Sage publications London.

Butler, J. 1993. Bodies that matter: on the discursive limits of sex. Routledge. London
Dennett, T. The Jo Spence Memorial Archives[online] available from; [accessed 01/06/14]

Dennett, T, Spence, J. 1982-86. The picture of health? [Online] available from: [accessed 01/06/14]

Glover-Graf,N . Miller, E 2005. The Use of Phototherapy in Group Treatment for Persons Who Are Chemically Dependent [online] Rehabilitation Counseling Bulletin April 2006 49: 166-181, Available from: [accessed 01/06/14]

Keedy, J. 2012 ‘ Its Hardly Noticeable’ [ online] Avalible From: [Accessed 01/06/14]

Mayberry,M. (2013). ‘Reducing Stigma of LGBT Youth Gay-Straight Alliances: Youth Empowerment and Working toward’. [Online] Available from: [Accessed 20/01/14]

Martin, R. 1999. Too close. [online] available from [accessed 01/06/14]

McNiff, S. (1981). The arts and psychotherapy. Springfield, IL: Thomas

Mental Health Foundation. Sexuality [online] available from [accessed02/06/14]

NHS choice. 2012 ‘ mental health issues if you’re gay [online] available from [accessed 01/06/14]

Muholi,Z. 2010. Faces and Phases. Prestel Publishing: London

Naish, J. 2014 (unpublished assignment) ‘The silence of stigma’ NI516 Everyday Values in Mental Health Nursing. School of Health Sciences, University of Brighton

PhotoVoice, Therapeutic Photography [online] available from [accessed 01/06/14]
Staricoff 2004 Arts in Health a review of medical literature. [Online] Arts Council England. Available from [access01/06/14].

Smith, S. and A.Grant. 2014. Facial Affect Recognition and Mental Health. Mental Health Practice 17(10) 12-16.

Warren, B. 2008. Using the creative arts in therapy and health care: a practical introduction. 3rdEd. Routledge: London
Weiser, J 2001-2014. Photo therapy techniques in counselling and therapy [online] available from [accessed 01/06/14]

Wheeler, J. 2012 The Therapy Room: Phototherapy and Therapeutic Photography [online]. Access Magazine, disability with no limits: available from[accessed 01/06/14]


Arts and Health: Creative Writing as a Reflective Method in Healthcare


In this essay I shall explore how creative writing can aid practitioners in the formation of therapeutic nursing relationships. I will first discuss some of the benefits and barriers to the establishment of the therapeutic relationship in nursing. I then turn to the potential of the use of the arts within health care, to establish reflective and self-aware practitioners. Following this, working towards closure of the essay, I turn to the value of reflective practice, including the benefits of creative writing to aid my awareness of self, particularly within the nursing role. In this context, I focus on my creative attempt, a fairy tale entitled The Girl and the Well, which can be found as an appendix to this essay, below the reference list.

Therapeutic relationships in nursing: benefits and barriers

All nurses must build partnerships and therapeutic relationships through safe, effective and non-discriminatory communication. They must take account of individual differences, capabilities and needs. (NMC 2010) To develop and inform our knowledge of patient health needs, nurses must build up a strong rapport with those in their care. They must establish a ‘therapeutic relationship’ (NMC 2010) in which patients feel able to express their needs, beliefs, social/cultural contexts and any pre-existing health knowledge. Good communication is essential in the negotiation of the therapeutic nurse and patient relationship. It has the potential to not only affect the actual care delivered but also how the patient perceives it. As Jootun and McGhee (2011, 41) state: ‘Poor communication can compromise care, which can lead to undue anxiety and frustration on the part of the patient’.

However, effective communication is a complex skill and can, particularly within nursing practice, prove problematic. Communication, as Balzer Riley states, ‘involves the reciprocal process in which messages are sent and received between two or more people’ (cited in Bach and Grant 2011, 11). These messages and delivered both consciously and subconsciously via body language, verbal discourse, eye contact, etc.

The communication process can become further distorted by the interpretation of these messages, which will inevitably be translated through individual schemas (Niven 1995). Schemas referred to an internal storage system informed by facts, experiences, beliefs and views, which we compare and contrast all new and incoming information to (Niven 1995). Processing this information allows us to make sense of our surroundings, to shape our social perception. However, the sense derived is not necessarily a universally accepted perception, as Niven and Robinson explain: ‘each individual’s different observations has been influenced by his or her background. The scene is constant, but the observations are different’ (1994, 40).

This highlights the fluidity of perceptions and their potential to become unconsciously prejudiced. In turn, this can lead to the individual selectively recalling information that can lead to the formation of what Oliver (1993) refers to as negativity bias. Individual prejudices and/or biases can form barriers to communication and therefore the successful formation of a therapeutic nursing relationship. Acknowledging that these barriers may be unconsciously constructed, how then do we as nurses overcome them and create ‘the right conditions for the development of mutual trust’? (Niven and Robinon 1994, 45).

The arts in health care

The nursing theorist Peplau (1952) proposed that is through the exploration of one’s ‘self’ that nurses may start to over come the barriers to therapeutic patient relationships. Peplau (1952, 12) argued that ‘Self insight operates as an essential tool and as a check in all nurse-patient relationships that are meant to be therapeutic’. This is a belief that remains popular in the twenty-first century and is supported by Freshwater (2002, 6): ‘Knowing and recognising self through self-awareness and self-consciousness … can be seen to be fundamental to the development of caring alliance which is to be therapeutic’. Wagner (2002, 121), further argues that the notion of self-awareness is fundamental to our understanding of what caring is:

Implicitly threaded throughout definitions of caring is the need to develop a sense of self, a sense of knowing ones beliefs and values, intention to help, moral commitment to be present, ability to respond competently to another’s need, and willingness to entre therapeutic relationships that encourage human connectedness.

So, how then does the nurse become more self-aware? Wagner (2002, 128) suggests ‘art therapy’ as a possible means, explaining that through the creative process one can unearth the ‘expressions of the unconscious psyche’. The use of artistic methods of expression in health is also promoted by Staricoff (2004, 24), who declared that the ‘relationship between the arts, particularly literature and medicine, stimulates insights into shared human experiences and individual difference, and increases the language and thoughts of the practitioner’.

Staricoff argues for the importance of literary works, which contemplate issues of illness and death, as a valuable resource for practitioners to aid reflection on clinical practice. Wagner (2002) extends on this argument in his assertion that, while the benefits of studying established artists’ work are clear, healthcare practitioners should personally participate in the creative process in order to develop greater awareness of self and personal knowing. However, the creative process and the encouraged confrontation of personal experience is not always an appealing or easy task particularly to those who have been encouraged to focus on the science of nursing and not its art.

The value of reflection

Reflection on and in practice is a process, which has long been encouraged in nursing and nursing education (NMC 2010). As a students nurse I have been encouraged to reflect on my experiences of nursing practice with placement mentors. Indeed, it is an NMC competency, which they have assessed my ability to engage in.

However, not until a recent meeting with my mentor did I fully appreciate the importance of self-refection and the impact it might have on my practice. During this meeting my mentor asked me to reflect on any personal barriers I might have which would prevent me from delivering care. My initial inclination was to reply in the negative; after all I came to nursing with the simple desire to care. However, I wanted to give her enquiry the reflection and attention it deserved and so I took my time to consider my personal values and beliefs.

This led to a consideration of how I have come to hold my personal values and beliefs, my experiences of life so far. In doing so, a somewhat contentious personal memory was re-surfaced, one that I was not aware still had to power to bother me. As with most unwanted/painful memories my initial response was to push it aware, ignore it and hope it goes away. However, through it surfacing I realised this memory/experiences was most likely the sort of potential issue my mentor wanted me to be aware of.

This was clearly an issue, that should I be reminded of it during practice, consciously or subconsciously, could effect my delivery of care. My unwanted memory was from my childhood experiences of living with a parent suffering from alcoholism. Alcohol addiction remains a predominant issue it the UK with ‘1.2 million alcohol-related hospital admissions in England in the year 2011/12, a 135% increase since 2002/03 (Alcohol Concern, 2014) It is inevitable that in my role as a student nurse (and a future registered nurse) I will be delivering care to patients effected by alcohol abuse. This is an issue I needed to reflect on more deeply on to ensure it did not ever bias my care.

I decided to use creative writing as a therapeutic technique to explore this issue. To gain a better understanding of my self in the hope that an increased self-awareness would deconstruct any barriers I may construct to in the attempted formation of therapeutic relationships with my patients. Creative narratives offer the writer permission to explore their own story (Grant et al. 2011) and thus use the art of storytelling therapeutically. Slater (2005,4) similarly argues that creative writing is therapeutic as ‘your own fears and short-comings will find expression in the process… the stories you generate will at once reveal to you your mind while offering up chances to change it.

However, while the reflective output from my creative endeavors promised to be beneficial to my future nursing practice, I found myself daunted by this personal and emotional task and sought some creative distance from it. I found my distance in the simplistic and symbolic style of the fairy tale. In the security of the traditional fairy tale third person narrative I reflected on my experiences of my mothers descent into alcohol addiction when I was a child. This narrative choice was not only elected to maintain fidelity to my genre’s structure but also for the theoretical therapeutic distance it provides. By writing in the third person, in a fantasy world of undefined time and place, using symbols and metaphors to represent emotionally painful issues and events, one can externalize one’s feelings and thoughts without having to explicitly confront them directly. I found this technique worked as a sort of mediator between my realistic memories and the feelings that arise from them. It is the symbolic nature of fairy tales, which have made them a useful and respected therapeutic device in the emotional treatment of children and adults (Brun et al. 1993).

In reflecting on my piece The Girl and the Well, I became aware of its somewhat typical representation of Freud’s theory of separation anxiety. This was expressed well by Bettelheim (1976, 145), who stated: ‘no greater threat in life than that we will be deserted, left all alone. Psychoanalysis has named this – man’s greatest fear – separation anxiety; and the younger we are, the more excruciating is our anxiety when we feel deserted’.

In acknowledging this Freudian interpretation I was able to accept and reflect and on potential feelings of anger at the neglect of myself as a child. In representing my mother I incorporated the formulaic fairy tale element of ‘splitting’ (Warner 1995, 212), a conscious writing strategy that divides the mother figure into two different characters, the ‘good’ mother and the ‘bad’ mother. The severing of the mother figure into these morally polarized beings allows me as the writer to ‘preserve an internal all-good mother when the real mother in not all-good … [and] permits anger at the bad mother’ (Warner 1995, 212). This strategy allowed me to really reflect on my more complex and conflicting feelings about my mother, a process that I found surprisingly cathartic.

Although I found creative writing for self-reflection an overall positive experience, it was a long process. I didn’t just write the entirety of my story in one sitting and feel suddenly healed and enlightened. It took time. It was a reflective period in which I felt completed to read and not just write. I remembered, sought out and re-read Sharon Olds (1987) poem ‘After 37 Years My Mother Apologizes for My Childhood’, which I feel aided my reflection and helped construct the image of my mother in the my tale. At this stage I feel ready to let my fairy tale go, it has served its purpose and provided ‘testimony’ (Grant 2011, 2) to my lived experiences.


I feel that my attempt at utilizing creative writing to explore my self, and therefore become a more self-aware caregiver, was successful. A nurse’s beliefs can be, as Ersser (2002, 56) argues, be ‘communicated to the patient with or without intention’, which highlights just how important it is for nurses to be self-aware in practice. Although I would never knowingly behave in a prejudiced way towards my patients, I feel this deeper reflection has made me more aware of a pre-existing potential issue, which I have had the proactive opportunity to work on. It has also made me more appreciative of the personal narratives patients have and that are always being constructed. As, Slater (2005, 11) argues, ‘Everyone, absolutely everyone had a tale to tell. And everyone, absolutely everyone will have to revise it, only to revise it again’. I believe the learning process has allowed me the freedom to really develop myself independently as a reflective writer and nursing practitioner, a progression I’m not sure I would have been able to succeed to in a more formally structured module.

Charlotte Pendlington, BSc (Hons) Nursing (Mental Health) student


Alcohol Concern. 2014. Campaign: Statistics on Alcohol [website] [ accessed 20 May 2014]

Bach, S. and A. Grant. 2011. Communication & Interpersonal Skills for Nurses. 2nd ed. Exeter: Learning Matters.

Bettelheim, B. 1976. The Uses of Enchantment: The Meaning and Importance of Fairy Tales. London: Thames and Hudson.

Brun, B., E. W. Pedersen and M. Runberg. 1993. Symbols of the Soul: Therapy and Guidance Through Fairy Tales. London: Jessica Kingsley Publishers Ltd.

Ersser, S.J. 2002. The presentation of the nurse: a neglected dimension of the therapeutic nurse-patient interaction? In: Nursing as Therapy. 2nd ed. edited by McMahon, R and A. Pearson. Cheltenham: Nelson Thornes Ltd.

Freshwater, D. 2002. The Therapeutic Use of Self in Nursing. [Online] London: Sage Publications. Available from: [Accessed 15 May 2014].

Grant, A., F. Bailey and H. Walker. 2011. Our encounters with madness. Ross-on-Wye: PCSS Books.

Grant, A. 2011. Introduction: Learning for narrative accounts of the experience of mental health challenges. In: Our encounters with madness, edited by Grant, A., F. Bailey and H. Walker. Ross-on-Wye: PCSS Books.

Jootun, D. and G. McGhee. 2011. Effective communication with people who have dementia. Nursing Standard. 25(25): 40-46.

Niven, N. 1995. Health Psychology: An Introduction for Nurses and Other Health Care Professionals. 2nd ed. Edinburgh: Churchill Livingstone: 25-42.

Niven. N and J. Robinson. 1994. The Psychology of Nursing Care. Leicester: BPS Books: 39-64.

Nursing and Midwifery Council. 2010. The code: Standards of conduct, performance and ethics for nurses and midwives. [Online] London: Nursing and Midwifery Council. Available from: [Accessed 20 May 2014].

Olds, S. 1987. The Gold Cell. New York: Knopf.

Oliver, R. W. 1993. Psychology & Health Care. London: Billlière Tindall: 159-176.

Peplau, H. E. 1952. Interpersonal Relations in Nursing. New York: Putnam.

Slater, L. 2005. Blue Beyond Blue: Extraordinary Tales for Ordinary Dilemmas. London: W. W. Norton & Company Ltd.

Staricoff, R.L. 2004. Arts in Health: a review of the medical literature. London: Arts Council England.

Wagner, A.L. 2002. Nursing Students Development in Caring Self Through Creative Reflective Practice. In: Therapeutic Nursing: Improving Nursing Care Through Self-Awareness and Reflection, edited by D. Freshwater. London: SAGE Publications Ltd.

Warner, M. 1995. From the Beast to the Blonde: On Fairy Tales and Their Tellers. London: Vintage.

The Girl and the Well

girl&woodOnce upon a time, there was a little girl who lived in the heart of a dark forest. Her name was Little Rose and once upon a time she had been happy. Little Rose had grown up in the comfort of a cosy cottage with her young and beautiful mother whom she loved dearly. Although she considered herself content, Little Rose’s mother was a curious woman with a longing to travel and know all there was to know about the world. One day, tiresome of their modest cottage, Little Rose’s mother announced that she was to journey alone into the forest in search of new and exciting delights to return home with. “Oh Mother,” sobbed Little Rose “please do not go! Or, if you must, take me with you. I won’t be any trouble.” Unaltered by her child’s pleas Little Rose’s mother kissed her daughter on the cheek, made her promise not to leave the cottage, and set out upon her expedition alone.

All alone Little Rose sat by the cottage window and awaited her mother’s return. Years past and yet Little Rose kept her little nose pressed against the pane of glass, willing her mother to walk through the clearing to their cottage; to return home. One day, to her great joy, Little Rose did see her mother emerge from out of the trees and towards their little cottage. “Oh Mother, you have returned to me! You are home. How I have missed you,” shrieked Little Rose as she ran to embrace her mother. However, as she got closer she froze and gasped. The woman in front of her, although with a likeness to her mother, was old and haggard. “You are not my Mother! My Mother is beautiful with a sweet face and fare skin. Your skin is sallow, your mouth is mean, your eyes are red. Oh where is my Mother? What have you done to her?” cried Little Rose. Irritated by the child’s wails, the changed mother pushed her daughter aside with a rough dirty hand, entered the cottage and closed the door behind her.

Left outside, on the other side of the door, Little Rose fell to the ground and sobbed. After a time, when she felt herself more steady, she picked herself up and crept to the window. Carefully peering through, she looked in horror at the sight which presented itself before her. There on the bed was her mother, she was not asleep but awake, breathing smoke, drinking a blood red potion and cackling a strange broken laugh. Her head was swaying an unnatural sway as she began to cough, sending forth hideous flecks of red and yellow slime from clenched cracked black teeth. “This monster is not Mother,” whispered Little Rose as she backed away from the door of her once happy home. “I shall find Mother and together we shall rid our home of this false creature,” vowed Little Rose.

All alone Little Rose set out for the first time into the woods in search of the loving mother she remembered. The woods were dark and unwelcoming and as Little Rose tried to make her way through the masses of unruly branches her hair and clothes were seized and shredded by sharp thorns. As night approached, and the little light that shone through the trees died, the woods became alive with the sound of wild and angry animals shrieking, hissing and growling their warning to those unfortunate enough to cross their path. Hungry and cold, Little Rose persisted on her desperate journey, wandering in circles and calling out for her lost loving mother. “Oh Mother, shall we ever find each other?” As she sobbed these words a worn old owl flew down and perched upon a branch close to where Little Rose lay. “Do not cry Rose, I can tell you where your mother is,” softy hooted the owl. “Where? Please tell me at once! I beg you!” implored Little Rose. Suddenly with a wide sweep of his wings the owl took flight and glided off in and out of the trees, “follow me,” he hooted as he disappeared into a mass of vines and leaves.

Pushing her way through the dense brier Little Rose came to a dry barren patch of earth upon which stood a rickety stone well. The owl perched itself upon the edge of the well hooting “here you are Rose, just as you asked.” Bewildered and overwhelmed with disappointment Rose began to yell “how could you? How could you be so cruel? My mother is not here! Oh, I am all alone and I will never see her again.” As her cries became whimpers the owl flew down and placed itself next to Little Rose sighing softly “you are not alone Rose, and you are not a little girl anymore, see how you have grown.” Rose looked down at her self and gasped, it was true she was no longer a child, indeed she was now a grown woman.

“Once upon a time,” continued the owl “a young woman entered these woods thirsty for adventure and exotic treasures, dissatisfied with the riches her life already held, she let her blind and selfish greed guide her on her journey and it led her to this very well. This is the ‘well of temptation’ and only those willing to forsake their souls to it may drink from it.” Rose slowly stepped toward the well and begrudgingly peered into its depths, “the blood red potion,” she exclaimed “oh mother, was I not enough for you?” The owl stared hard at Rose, “what do you wish to do now my dear? Perhaps you too would like to partake from the well? Or perhaps your heart yearns to return home?”, questioned the owl. Rose glanced again at the well, the thick red liquid was rich and velvety, its aroma strong and enticing. “I am so thirsty” murmured Rose, “maybe I should have just a little … I have no home now … even if I do wish to return there.”

She lowered the old pail into the well and once it was full carefully drew it back towards herself, she lifted it towards her lips and was about to take her first sip when she froze in horror. There staring back at her, reflected in the alluring liquid, was the haggard sallow face which had possessed her mother. “No” she cried, “No, this is not what I want! I want to go home! I want to go home!” As she declared her last words Rose threw the pail back into the well and ran as fast as she could out of the barren land and through the woods. She passed vines and brambles shouting to them “I want to go home!” and as she did they parted, clearing her way. She ran into the darkest part of the woods and shouted at the hidden sky “I want to go home!” and suddenly the trees swayed their branches aside letting the newly risen sun shine through. “I want to go home!” she yelled once again and as she did she ran out of the trees into a clearing leading to a lovely little cottage. Rose stopped in front of the cottage. Suddenly the cottage door flew open and out ran a beautiful little girl calling “Mother! Oh Mother you have returned! You have come back to your Little Rose!” Rose took the little girl in her arms, kissed her on the cheek and softly whispered “yes my little one, Mother is here, Mother is home.” Hand in hand they walked together back into the cottage where they lived together happily ever after.



The 15th Annual Mental Health Conference – 9th April 2014

The beautiful thing about learning is that no one can take it away from you (BB King)

The 15th Annual Mental Health Conference was marked by one of the first truly sunny days of the year and the feeling of warmth that this gave was carried into the conference itself. In the canteen, as everyone filled up on coffee, it was a delight to see quite a few of the usual suspects and a smattering of new faces
The proceedings started with a brief introduction from Sharon Davies who announced that the conference has now acquired charity status. This should help with raising funds, ensuring that it runs annually and is free to all who attend. As Sharon said, there are those who would not attend regularly if there were a cost attached, so this was important and positive news.
The Marion Beeforth memorial lecture this year was given jointly by Sara Meddings, Diana Byrne and Hazel Lambe. They have all been involved in setting up a pilot project to establish Recovery Colleges in the Sussex area. The two initial projects were in Brighton & Hove and Hastings and it looks like they have both been a great success. Recovery Colleges are a pioneering way of helping people with a mental health diagnosis (or their carers) to cope with their illness, to take charge of their own recovery process and to live a freer and more fulfilling life. Having been established in various parts of the country, Sara and the team are now planning to open colleges in various parts of Sussex.
Sara told us that the principles behind the college are that they bring together people with lived experience and clinical training and that the expertise of both these groups is acknowledged and given equal status. The colleges offer a range of courses to teach people coping strategies and applicants can choose from prospectuses courses that will suit them best and then, at the end of the course, they receive a certificate celebrating their success.
One of the great things about these colleges is that they ‘recycle’. Students can, if they wish, become teachers, thus bringing their own skills to the mix. Diana talked us through how this worked and how valuing it is to be able to bring one’s own experiences to the table to help others.
Finally we heard from Hazel who had graduated as a student from the Recovery College. She told us how rewarding she had found the process, how she felt that she had ‘re-engaged’ her brain and how she was now training to be one of the Peer Support Workers.
It was a truly inspiring presentation of an initiative that looks as though it may fill a huge gap for many people who have experience of mental illness. One of the overwhelming impressions was that the Recovery College provided some thing that had been missing for many people – hope.
After the presentation the conference divided into group work sessions that, on returning, fed back their thoughts on the Recovery College initiative. Feedback was, unsurprisingly, overwhelmingly positive. It really felt like the sunshine had followed us into the conference and stayed there.

Steve Smith Mental Health Nursing BSc(Hons) student

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