Guidelines for mental health practice with clients who engage in sex work

Abstract

Many mental health practitioners have had or will have the opportunity to work with clients who engage in sex work (CSW). Sex work stigma is pervasive in the general population, and among mental health professionals, including sex and relationship therapists. Such stigma may lead to differential, unfair, and even unethical treatment of CSW. Although there is a clear need for best practice guidelines for mental health practice with CSW, no guidelines have been developed thus far. Therefore, drawing on feminist, multicultural, and sex-positive philosophies, this paper presents ten guidelines that are designed to: (1) address and increase mental health professionals’ self-awareness of their own bias about sex work; (2) provide useful information about the multifaceted lived experience of CSW; and (3) offer culturally-appropriate counseling skills and intervention strategies in working with CSW. Acknowledging that multicultural competence is a professional process, rather than an outcome or an end, the guidelines included in this paper are developed with the underlying assumption that all mental health professionals are committed to be sex work-affirming and competent in working with CSW, regardless of therapeutic orientation. The guidelines discussed in this paper are informed by current literature about sex work and people who engage in it.     

Experiences of stigma and discrimination as predictors of mental health help-seeking among sex workers

Abstract

Sex workers face higher levels of stigma and discrimination than those in other service professions, this stigma and discrimination is a potential barrier to seeking mental health support. We surveyed 189 sex workers internationally on their perceived experiences of stigma, discrimination, and mental health help-seeking. It was anticipated that a large portion would report experiences of stigma and discrimination from mental health professionals and in mental health settings. Furthermore, that perceived devaluation and discrimination would predict a lower likelihood of past help-seeking from psychologists and psychiatrists, and perceived experiences of stigma and discrimination would predict a lower likelihood of future mental health help-seeking. We found that perceived devaluation and discrimination predicted lower past help-seeking from psychiatrists, and that past perceived experiences of stigma and discrimination by mental health professionals significantly predicted a lower likelihood of future help-seeking. No other significant effects were found. Results demonstrated a concerning level of stigma and discrimination experienced by sex workers when seeking mental health support, and that such experiences were demonstrated to significantly impact on the intention to seek future mental health support. Implications of these findings, as well as directions for future research in this relatively new field are discussed.     

Bottoms up: a whorelistic literature review and commentary on sex workers’ romantic relationships

Abstract

In the field of sex work research, recent decades of scholarship have witnessed an increase in a holistic approach to examining the experiences of this marginalized population. While scholars have examined various aspects of sex workers’ lives, holistic research on their romantic relationships is scarce. However, at the same time, outside the realm of academia, sex workers themselves have been producing their own discourse to approach the various facets they uniquely face in these relationships. Thus, this literature review and commentary analyzes both academic and sex worker published materials.     

Sex worker affirmative therapy: conceptualization and case study

Abstract

Prior research reported some segments of the sex worker population are at higher risks of negative health outcomes. Historically, these outcomes were viewed as a result of the work itself without taking into consideration the role of the stigma and often criminalization of the work that may be the contributing factors impacting distress. Therefore, drawing upon minority stress theory and affirmative therapy guidelines for the LGBT population, this article conceptualizes sex workers’ mental health through a lens of stigma and stigma management. From this conceptualization, the article presents competency, assessment, and treatment principles to serve as the basis for sex worker affirmative therapy. A case study detailing a sex worker’s struggles with boundary setting and establishing romantic relationships is presented to highlight how sex worker affirmative therapy can be applied in clinical practice.     

Mental health of migrant workers in China: prevalence and correlates

BACKGROUND: This study aimed to examine the prevalence and the socio-demographic correlates of mental health of migrant workers in Shanghai China. METHODS: A total of 475 migrant workers from four major districts in Shanghai were recruited through a survey design with a multistage cluster [corrected] sampling. Male and female migrant workers were identified as mentally healthy or unhealthy using the brief symptom inventory. Socio-demographic characteristics and migration stress were explored as correlates of the mental health of the migrant workers. RESULTS: A total of 73 migrant workers could be classified as mentally unhealthy (25% for men and 6% for women). Male migrant workers who were married (OR 6.16, 95% CI 1.83-20.70), manual laborers (OR 1.56, 95% CI 0.97-2.51), and experienced more stress in "financial and employment-related difficulties" (OR 2.75, 95% CI 1.47-5.14) and "interpersonal tensions and conflicts" (OR 4.18, 95% CI 1.55-11.25) were more likely to be mentally unhealthy, whereas the female migrant workers who experienced more stress in "interpersonal tensions and conflicts" (OR 6.52, 95% CI 0.83-51.14) were more likely to have poor mental health. CONCLUSION: The findings provide information for the prevention of mental illness among migrant workers in China. The implications and limitations are also discussed.     

Poverty and mental health: a qualitative study of residential care facility tenants

The impact of poverty on daily living was assessed for twenty-two mental health consumers using qualitative in-depth interviews. Consumers reported considerable difficulty meeting basic needs, such as clothing, shoes and personal care items. A majority reported running out of money before the end of each month. Respondents used strategies including careful budgeting, borrowing and employment to cope with poverty. Analysis indicated that the poverty experienced by respondents worked directly against participation in meaningful activities and their ability to build and sustain social relationships. Moreover, poverty directly contributed to stigma experienced by respondents. Findings suggest that a failure to recognize poverty as a key mental health policy issue will continue to constrain efforts to facilitate consumer empowerment and social integration.     

Safety skills of mental health workers: empirical evidence of a risk management strategy

To reduce violence in the workplace, health care facilities invest time and resources in risk management strategies such as photo identification and controlled access and surveillance. Studies of assaultive psychiatric patients continue to document that mental health workers (MHWs) are the most frequent targets of the patient violence. Unexamined in these findings is the role skilled MHWs contribute in restoring safety and order in the aftermath of these assaults. This six-year, empirical retrospective study examined the safety skills of MHWs in containing violence. Although they were 28% of the workforce, MHWs restored order in the majority of single assault incidents and restraint procedures. Their skills appear to be a risk management strategy in their own right. The implications are discussed.     

A survey of burnout among Australian mental health occupational therapists and social workers

Abstract. Background: This study investigated the extent to which occupational therapists and social workers employed in Australian mental health settings are affected by burnout. Method: Questionnaires were sent to occupational therapists and social workers who had indicated that they were interested in participating in the study. An overall response rate of 76.6% (n = 304) was achieved. The outcome measure was the Maslach Burnout Inventory (comprising emotional exhaustion, depersonalisation and personal accomplishment scales). Results: There were no significant differences, with respect to any of the three burnout scales, between occupational therapists and social workers. Both groups experienced high emotional exhaustion, moderate depersonalisation, and high personal accomplishment. Levels of burnout were not significantly different between inpatient and community staff. Conclusions: These results suggested that, while occupational therapists and social workers reported emotional exhaustion, there was less evidence of depersonalisation and they reported very high personal accomplishment in their work. Results are congruent with those of previous studies and it is argued that the focus of future research should be on identifying characteristics of mental health work that contribute to emotional exhaustion.     

Mental health knowledge and training needs among direct care workers: a mixed methods study

Objectives: Direct care providers (DCWs) spend the most time with clients in the home, and as such, play an integral role in identifying mental health problems. However, DCWs receive little preparation in mental health and there is little research regarding their role in the mental health care of clients. The purpose of this study was to explore DCWs’ knowledge, attitudes, and experiences of caring for clients with mental health problems from the perspectives of DCWs and key administrators (KAs).

Method: Mixed method design. Structured interviews were conducted with DCWs. Focus groups were conducted with KAs.

Results: Twenty-nine DCWs and 12 KAs took part in the study. Loneliness and memory problems in clients were the most prevalent challenges identified by DCWs. DCWs’ self-reported mental health knowledge was mid to high across all domains, although they had many misconceptions about mental health and aging. Helpful strategies in working with clients included communication skills, rapport-building, behavioral, cognitive, emotion-regulation, and making use of external resources. KAs noted individual differences in DCWs’ mental health knowledge and indicated that mental health issues were often viewed by DCWs as dispositional problems or a normal part of aging. KAs viewed DCWs’ greatest challenges as personalizing difficult client behaviors, lack of knowledge about how to manage specific behaviors, and difficulties managing their own emotions towards clients.

Conclusion: Data from this study suggest important areas for DCW development. However, system issues that affect DCWs such as workload, resources, mental health stigma, and diverse client populations should be addressed concurrently.     

Training,attitudes and practice of district health workers in Kenya

BACKGROUND: The 1994 mental health policy in Kenya was rooted in the concepts of Primary Health Care articulated at Alma Ata, and required that mental health care be decentralized to all levels of the health care system, and delivered by all cadres of health staff rather than just mental health specialists. However, effective implementation of this policy was likely to be influenced by the degree to which the training, attitudes and practice of health staff was consistent with and supportive of the mental health policy. OBJECTIVE: This article therefore reports a study conducted in 1997, which examined the training, attitudes and practice of district level health staff in relation to mental health care and compared them with the national mental health policy of 1994. METHOD: A semi-structured questionnaire was sent to the medical superintendents of all district hospitals in Kenya, for distribution to respondents from each cadre of health staff. A total of 148 health workers from 28 districts out of 44 eligible districts (63%) responded. RESULTS: District health workers did not think general health workers ought to manage most psychiatric patients, even if they were capable of doing so, preferring a system where these patients were managed by specialists and were not admitted into general wards. They also tended to equate mental illness with psychosis. CONCLUSION: Despite their training in mental health care and their theoretical knowledge of the principles of Primary Health Care, the attitude and mental health care practice of most health workers were in keeping with a more medical model of health care, emphasising pharmacological treatment and expecting psychiatric patients to conform to the standard Sick Role. This orientation, being at variance with the orientation of the 1994 mental health policy, may have contributed to difficulties in implementation of the policy.     

Socio-demographic and work setting correlates of poor mental health in a population sample of working Victorians: application in evidence-based intervention priority setting

Interventions to promote mental health in the workplace are rapidly gaining acceptability as a means to prevent, screen, treat and effectively manage the growing disease burden of depression and anxiety among working people. The objective of this study was to identify socio-demographic and work setting correlates of poor mental health to consider alongside other evidence in priority setting for workplace mental health promotion (MHP). Multiple logistic regression was used to model the probability of poor mental health (SF-12) in relation to socio-demographic (gender, age, education, marital status and occupational skill level) and employment factors (workplace size and type, industrial sector, employment arrangement and working hours) in a population-based cross-sectional survey of 1051 working Victorians. As a result, poor mental health was (21% prevalence overall) higher in working females than in males and decreased with increasing age. Only one employment factor was significant in demographically adjusted multivariate analyses, showing an increase in the odds of poor mental health with increasing working hours. It is concluded that based on the prevalence of poor mental health, Victorian work settings with high proportions of younger workers, and younger working women in particular, should be prioritized for workplace MHP. Thus, together with other research demonstrating particularly poor psychosocial working conditions for young working women, sectors with an over-representation of this group (e.g. service sector) could be prioritized for workplace MHP alongside young and blue-collar males (also a priority due to low mental healthcare service use).     

Recommendations of mental health professionals and the general population on how to treat mental disorders

Objective The objectives of the study are (1) to assess the mental health literacy of mental health professionals, (2) to determine whether there is agreement between different professional groups with respect to different psychopathological conditions and (3) to compare the professionals' knowledge with that of the general population. Methods Two representative samples of mental health professionals and laypersons were presented with a vignette depicting either a person with schizophrenia, major depression or without any psychiatric symptoms (‘non-case’). Out of 18 treatment proposals, the respondents were asked to indicate the proposals regarded as helpful and those considered as being harmful, respectively, for the person depicted. Results Mental health professionals view their profession and less often their treatment methods as helpful. Dealing with the situation alone, electroconvulsive therapy, hypnotics and sedatives are consistently regarded as harmful. For the individual with schizophrenia, mental health professionals agree about helpful treatments. Regarding depression, a lack of consensus is found about treatment proposals such as psychiatric hospitalisation, antidepressants and complementary and alternative medicine. An important part of mental health professionals suggests medical help (psychologists and general practitioners) for the non-case vignette. Fewer nurses, social workers, vocational workers and occupational therapists (‘other therapists’) as compared to psychiatrists and psychologists recommend standard treatment methods. Professionals and the general population significantly differ in their attitudes towards the treatment suggestions, especially regarding medication and alternative medicine. Conclusions To improve the treatment of mental disorders, various strategies must be considered. These include permanent education of all mental health professionals, especially nurses and other therapists. A special focus must be given to affective disorders and a potential (over-) treatment of normal behaviour.     

An integrated approach to workplace mental health: an Australian feasibility study

We developed and implemented an integrated workplace mental health promotion intervention combining job stress reduction with a workplace mental health literacy program. The intervention was evaluated using an uncontrolled design, with organizationorganisation-wide census employee surveys of working conditions and mental health literacy pre-intervention, followed by a 1-year action planning and intervention period, then a post-intervention survey. All employees were invited to be surveyed, and all respondents were included in analysis, independent of participation in intervention activities or employment status (44% response rate at baseline, 37% at final). No significant changes were observed in the targeted psychosocial working conditions – job control, job demands, and social support at work. In contrast, significant improvements in some aspects of mental health literacy were observed, particularly in helping behaviours. Acknowledging the limitations of this being an uncontrolled pilot study, our results suggest that it is feasible to integrate job stress and mental health literacy intervention, as well as evidence of sustained improvements in mental health literacy and the need for more intensive and sustained efforts to improve psychosocial working conditions.     

Connecting students to mental health care: pilot findings from an engagement program for school nurses

Schools function as the major provider of mental health services (MHS) for youth, but can struggle with engaging them in services. School nurses are well-positioned to facilitate referrals for MHS. This pilot study examined the feasibility, acceptability, and preliminary efficacy of an engagement protocol (EP) designed to enhance school nurses' utilization of evidence-based engagement practices when referring youth to MHS. Participants were six school nurses and 25 adolescents in a large, urban school district. School nurses reported positive attitudes toward the EP, suggesting that they found it feasible and acceptable. Though there were small increases in school nurses' use of engagement practices and in adolescents' readiness for services following training, due to limited sample size, differences were not statistically significant. Still, pilot results suggest preliminary efficacy of training school nurses to strategically implement evidence-based engagement practices to increase adolescents' engagement in MHS.     

The current state of mental health care in Italy: problems,perspectives, and lessons to learn

After legislative changes in 1978, Italian psychiatry underwent a thorough overhaul, with the gradual closure of all Mental Hospitals. A nation-wide network of Departments of Mental Health now deliver outpatient and inpatient care, but also run semi-residential and residential facilities (the latter with 2.9 beds per 10,000 inhabitants). Hospital care is delivered through small psychiatric units (with no more than 15 beds). There are also many private inpatient facilities operating in Italy, and the number of private inpatient beds per 10,000 inhabitants exceeds the number of public beds; overall there are 1.7 acute beds per 10,000 inhabitants—one of Europe’s currently lowest numbers. There is marked quanti- and qualitative variation in the provision of out- and inpatient care throughout the country, and service utilization patterns are similarly uneven. Studies examining quality of life report a fairly high degree of patient satisfaction, whereas patients’ families frequently bear a heavy burden. In conclusion, the Italian reform law led to the establishment of a broad network of facilities to meet diverse care needs. Further efforts are required to improve quality of care and to develop a more effectively integrated system. Greater attention must be paid to topics such as quality of care and outcomes, public and private sector balance, and the coordination of various resources and agencies.     

Care management, dementia care and specialist mental health services: an evaluation

OBJECTIVE: To evaluate a model of intensive case management for people with dementia based in a community-based mental health service for older people. METHOD: Quasi-experimental design. Individuals in one community team setting received case management and were compared with those in a similar team without such a service. Forty-three matched pairs were identified. Eligible older people and their carers were interviewed at uptake and again at 6 and 12 months. RESULTS: The impact of the scheme upon placement occurred in the second year at the end of which 51% of the experimental group remained at home compared with 33% of the comparison group. For the experimental group significant improvements in the social contacts of older people were noted; a decrease in the stress of their carers was observed, together with a reduction in their input to the care of the client; and there were significant improvements on ratings of overall need reduction, aspects of daily living and level of risk. Differences between the two groups based on service receipt showed higher costs for the experimental group. DISCUSSION: The benefits to older people and their carers confirms previous findings that the most effective case management interventions are those targeted on a highly specific client group. Issues which influence the cost-effectiveness of intensive case management are discussed. The benefits of locating this service within a specialist mental health team are explored in the context of current initiatives to promote greater service integration between health and social services.     

Health gain through health checks: improving access to primary health care for people with intellectual disability

People with intellectual disability were identified through the local register and through liaison with general practitioners (GPs). A consultation exercise was conducted with users and carers to ascertain their experiences and perspectives of primary health care (GP services). A comprehensive health check was devised and administered to about 120 people to detect physical disorders, especially cardiovascular risk factors. A standardized checklist was used to determine the population of people with psychological and psychiatric problems. Case notes were reviewed after nearly one year to determine physical and psychological health gain. Significant gains were noted with regard to physical disorders. In contrast, mental health problems were underreported and participants had achieved few gains on follow-up. The reasons and implications for future service planning are discussed.     

Integrative Care for Adolescents With Dual Diagnosis: Considering Trauma and Attachment Within an Innovative Model for Clinical Practice

Adolescents with intellectual disability are at significant risk for developing concomitant mental health and behavior problems. Youth who experience “dual diagnosis” face great challenges, and require interventions that will promote their autonomy, self-determination, and adaptive functioning. In this article, we devote attention to innovative components that have received less focus, but that we suggest have great relevance for this population, namely those related to attachment and trauma. We review research examining attachment- and trauma-informed care, and highlight practical approaches for which evidence is emerging. We suggest that a comprehensive treatment model must integrate well-validated and innovative treatment approaches, in order to address the complex clinical concerns of this population.