澳大利亞心理健康服務(wù)中消費者的意見英語

WHAT'SINASERVICE?CONSUMERS'VIEWSOFAUSTRALIANMENTALHEALTHSERVICESThispaperreportsonaseriesofinterviewswithconsumersofmentalhealthservices,conductedaspartoftheConsumerEvaluationofMentalHealthServicesproject(CEO-MHS).Withoneofouroverarchingaimsbeingtodevelopaconsumerorientedandconsumerdirectedmethodofevaluatingmentalhealthservices,weconsideredseekingconsumers'viewsofmentalhealthservices,usingqualitativeinterviews,tobeessential.ConsumerResearchersfromtheteamconducted33interviewsinNSW,Australia.Eleventhemesemergedfromanalysisoftheinterviewdataandthesethemesaredescribedindetail.ConsumerparticipationintheevaluationofservicesisincludedwithintheNationalStandardsforMentalHealthServicesinAustralia,andinternationallysimilarrecommendationsaremadeforinclusionofconsumersinserviceplanningandevaluation(CommonwealthofAustralia,1997;DepartmentofHealth,London,1999;USDepartmentofHealthandHumanServices,2001).Traditionally,methodsofevaluatingmentalhealthserviceshavebeendrivenbyprofessionals'perspectives(Campbell,1997;Prince&Prince,2001)despitemarkeddifferencesnotedbetweentheseandconsumers'constructsaboutwhatisdesirableand/oreffective(Gill,Pratt,&Librera,1998;Perkins,2001).Theaimofthispaperistoreportoninterviewsconductedwithmentalhealthconsumersduringlate2002andearly2003.TheinterviewsreportedherearesituatedwithinthecontextoftheConsumerEvaluationofMentalHealthServices(CEO-MHS)project,a3-yearprojectfundedbytheAustralianResearchCouncilandlllawarraHealth,aregionalmentalhealthserviceinNSW,Australia.CEO-MHSisacollaborativeprojectwithanoverallaimtodevelopamethodofevaluationofmentalhealthservices(Strangetal.,2001)fromaconsumerperspective,andcouldbedescribedasconsumerhealthresearch.InHunt'sdiscussionofconsumerhealthresearch,sheidentifiestheparametersofthisstyleofresearchas"researchconductedbyandwithconsumers"asopposedto"researchconductedonbehalfofconsumers"(1997:p.48),notingthisdistinctionrelatestowhocontrolstheresearchprocess.ConductingtheCEO-MHSprojectisateamofacademicandconsumerresearchers(CRs).Inapracticalsense,ourassertionthatthiscouldbedescribedasconsumerhealthresearch,webelieve,issupportedbytheworkreportedhere,asCRsfromtheteamplayedinstrumentalrolesintheinterviews,fromthestageofdevelopingtheinterviewguide,throughdatacollection,toanalyzingtranscriptsandinterpretingthemes.Ouraiminconductingtheinterviewswastoaddressthequestions:?Whataretheexperiencesofbeingaconsumerofpublicmentalhealthservices??Whataretheimportantaspectsofamentalhealthserviceforconsumers?Weconsidertheseimportantquestionstoaskgenerally,andadditionally,asnecessarytoouroverallaimofdevelopingaconsumerdirectedevaluationmethodformentalhealthservices.MethodConsumerResearchers(CRs),workingaspartoftheCEO-MHSteam,conductedtheinterviews,whichweretranscribed.Theirrolewastoguideparticipantsthroughthesemi-structuredinterview,posingthequestionswehaddevisedandkeepingthediscussionontopic.AnexplicitaspectoftheinterviewswasforCRstoconveyasenseofempathy,allowingtheparticipantstofeeltheirvoicewasbeingheard.CRshadattendedseveraltrainingsessionsinconductinginterviewsaspartoftheiremploymentontheCEO-MHSproject(McLeod&Oades,2001).Supportwasavailableinavarietyofformsforinterviewers,andwasexplicitlyviewedastheresponsibilityoftheentireresearchteam.Additionally,supervisionwasprovidedbythefirstauthor,whichinvolvedjointreflectionwithCRsontheirskillsasinterviewers.ParticipantsAtotalof33mentalhealthconsumersparticipatedininterviews,14malesand19females,ranginginagefrom20yearsto67years.Thestudyhadreceivedapprovalfromthehumanresearchethicsboardoftheaffiliateduniversity,andeachparticipantgaveinformedconsenttotakepartintheirinterview.Weadoptedapurposivesamplingmethod,seekingmaximumvariation,inrecruitinginterviewparticipants(Patton,1990).Purposivelyselectingparticipantsrecognizesagoalofattemptingtounderstandconsistentwithouraimandanalysismethod,comparedtothegoalofgeneralizationthatismorecommontoquantitativeresearch(Maykut&Morehouse,1994).Specifically,wesampledforconsumerswhohadarangeofexperienceswithdifferentservicesettings;typeandamountofcontactwithservices;geographicalsettingofservicesused;culturalandlinguisticbackgrounds;mentalhealthliteracy;andchoiceintreatment,intermsofperceivingthemselvesasvoluntaryorinvoluntaryclientsofmentalhealthservices.Inadditiontotheseareas,wesoughttobalancegenderandensuredarangeofages.Thesesamplingareasweredeterminedthroughaseriesofteammeetingsconsideringthequestion:?\Nhataretheimportantvariablesthatmayaffectconsumers'experiencesofpublicmentalhealthservices?Feedbackfromexternalconsumerconsultantswasincorporatedintothediscussions.TheInterviewGuideOurinterviewquestionsweredevelopedbasedinpartaroundthemesthathademergedfromfocusgroupdiscussionsourteamheldwithmentalhealthconsumerspreviously(Malins,Oades&Viney,2003).TwogroupsofCRsfromtheteamindependentlydraftedaproposalfortheinterviewquestions,usingthethemesfromthefocusgroups.Aseriesofmeetingsdiscussingthetwoproposalswerethenheld,withCRandacademicmembersoftheteamrefiningandstructuringthefinalinterviewquestions.Theresultinginterviewguideconsistedofeightquestions:thefirsttwowerebroadopen-endedquestionsinvitingparticipantstodiscusstheirviewsofmentalhealthservicesgenerallyandtheothersixquestionsrevolvedaroundissuesidentifiedinanalysisofthefocusgroups.Giventhesemi-structurednatureoftheinterviews,eachoftheseeightquestionswasfollowedwithaseriesofpromptsthatCRsutilizedininterviewsasnecessary.AnalysisThefirstandlastauthorsconductedanalysesoftheinterviewtranscriptsusingtheInterpretativePhenomenologicalAnalysismethod(IPA)(Smith,Jarman&Osborn,1999).Thefirstauthorconductedanalysisusing33transcriptswhilethelastanalyzed2/3ofthetranscripts.IPAoffersacomprehensiveprocessforconductinganalysis,describedbybothSmithetal.(1999)andWillig(2001)andwaschosenasthemethodofanalysisbecauseofitsfocusonpersonalmeanings,whilecentrallyrecognizingtheinterpretativeprocessofanalysis(Smithetal.,1999).SeparateanalysesusingtheIPAmethodwereconducted,andthenmasterlistsofthemeswerecompared,asingleinclusiveinterpretationbeingdevelopedfromthetwoanalyses.油St醋ig腦ma拔a樣nd糞A燥cc晴ep余ta晃nc購e章Th墓is屑t伏he域me顧r咱ep彈re鐘se擾nt坑s校pa墾rt幫ic博ip劍an逃ts宰'瞧di叮re獲ct注di撤sc功us姥si四on維o緒f散st鑄ig甲ma樹a墾s逐an辦i押ss偶ue解fo運r岔th本em辣,蘿wi項th牲in積m杜en軍ta礦l耕he滔al晝th姨s懼er余vi喇ce齊s,狗wi鳳th腥in榆t險he菌c亦om酒mu銅ni防ty辜,愛an奶d古fo沾r找th室em曾se隙lv馳es芒.欄Fo圓r膨ex途am奉pl背e,壁o減ne危p梁ar偵ti據(jù)ci駛pa殖nt層sa居ys稍:濱I棋th煎in蠶k槽th孝at扶's堡t浸he比b矮ig忘o脖ne修a唐bo哪ut造t充he些m玩no娛t南tr顯ea滅ti搶ng請m誠e臂li指ke堤a立p快er竿so妥n.取As鑰t黃hi族s資pa蹤rt究ic遲ip超an蜜t引go橫es游o似n販to在t她el腹l辱he酷r旦st杜or肝y,根s陳he破r壯el侵ay絲s承th餐is蜜e杏xp統(tǒng)er案ie上nc債e:稀A厲do蜜ct村or謀f接ro淋m賓ou施t亂of殊h種er統(tǒng)e訪st軋op材pe夠d焰me鐮i秋n努th退e銀mi漠dd美le憶o胡f掏th偷e哄st白re婚et鵲a梳nd享p摩oi釋nt兼ed嘉t把o琴al醬l搏hi妙s軋of不f-負si嗓de悔d賓oc啦to浮rs居—t樓ra驢in巡ee升d琴oc罩to扇rs嘉—膽pu嬌ll貨ed驕u冤p疤my竟s右le廊ev痰e奏an鈔d.宗..昂sa俱id謎"l寇oo案k沫at售t圖hi設(shè)s迎st緞up涉id姓g往ir終l,鴉c輔ut笛ti田ng廢唐he托rs怨el鉛f尺an望d.駛..廉th曠at攝d歉ev嬌as勁ta瑞te吳d淘me陷."粘(品Pa僵rt刊ic眉ip胳an扔t鞠11傾).辛In牲fo刷rm巴at吐io始n真an逼d印Ed臨uc令at媽io陶nMostcommonly,participantsdiscussedthelackofinformationtheyreceive.Thisrelatestoavarietyofareasofserviceprovision,forexamplelackofinformationaboutmedication,andabouttheirdiagnosis.Oneparticipant克sa違id搶,思in森r孫el及ay泊in嘉g紋a癥st運or螺y都ab紫ou零t晴be緒in斷g動pr竿ov絡(luò)id誠ed太w役it艙h職ne孩w爽me必di揭ca午ti糖on中:倦Th賞at早's談v泊er孕y幕po昏or甚,辭ju狠st字b盜ei伐ng章p傭ut視o扒n響a縮ne鍋w肆me土di羅ca嗎t(yī)i軍on紋.齡I踐wo鳴ul異dn歲't育e船ve癢n煉[h臣av找e]痛h塊ad示th忌e怕na詢me魚o怪f傲it三w屆ri順tt點en膛d池ow所n隆un味le頂ss迎I鍵sp兩ec枕if蠅ic菊al想ly陳a濱sk罷ed孩s延om伐eo隱ne傻t瓦o談wr垃it珠e弄it抱do癥wn比f姑or濤m暑e.怎I扭s俗ti勾ll丈d飲on醬't掘h微av主e蒸an痰y脅of碌t俯he漸li區(qū)st拼o縣f浙si抓de辮-e菊ff牽ec來ts膚t日ha串t久it偽c繳au冊se杏s.驢..繪if咳y月ou鮮wa烏nt噴a稍ny的i婆nf荷or促ma靜ti唯on曉a標(biāo)bo林ut喘m己ed美ic辭at讓io鳳n啄yo墾u'懶ve戶g丙ot睜t擊o準sp掩ec咐if帽ic鳥al皆ly北a旦sk普f研or提i洽t,抱y什ou育kn之ow護w赴ha討t醉I軋me蜓an扇?相Th內(nèi)en澤y歷ou驕a芝re績l饒uc艷ky歐to輛g硬et辯i怨t!壓(肉Pa野rt泡ic泳ip哨an域t激18磁).瘡Se甲ve坐ra預(yù)l添pa趕rt準ic風(fēng)ip越an弦ts賓r鄙ef竭er吼t各o賤se缸ek駛in光g驚in胡fo裙rm吉at課io蘿n膛ou丸ts添id才e裕of報th坡e苦sy劈st朗em觀:今bo值rr農(nóng)ow燙in現(xiàn)g蛛or扁b纏uy烤in纖g冊bo自ok某s,澤a崗nd就w乞at紡ch遙in闖g閑te玩le證vi旗si芹on飄p緣ro紋gr茄am綱s占an比d定us射ef煤ul獸v伸id則eo玉s.奇An廳ot炎he燃r鞠as溪pe來ct梢o塌f丟th綁e座th沾em土e葉re猴la凳te咐s荒to智be往in嚇g捎in紐fo胸rm守ed魔,炕as當(dāng)d役is沾ti肢nc瓶t偶fr觸om位a必cc兵es涂si肥ng見in蘋fo爆rm矮at料io演n,役h車ow街ev越er伙s嗎im粉il喊ar植ly辰,憂is貿(mào)m殲os疼t懷fr系eq廳ue緩nt牛ly紀r挽ai陵se瓦d濾in原t禮er胖ms處o賄f價pa爸rt獻ic猴ip雷an痛ts溝'捧se創(chuàng)ns孕e拾of破t坊he備l穩(wěn)ac仿k雪of購b仰ei鈔ng旁ke香pt欣i混nf盼or鋒me叢d.揀B儉ei漆ng庫i烈nf勵or叉me多d仿ha蕩s找a唉mo喂re聯(lián)p酸er瘋so芬na森l絹fo貪cu越s齒th刻an炮a腫cc閃es板s航to板i襖nf武or氣ma哄ti脂on示,曬re黃la礦ti芹ng鄰t賊o優(yōu)co凍ns絞um克er慣s'佛o臘wn鄰ca羨re蜘a隊nd獨r辛ol盤e斧in冬t愛he健s御er食vi艙ce茅.挎Bo已th括h昌av正in眠g興ac輪ce則ss遍t興o扇in看fo麻rm促at乓io川n蠟an裙d嗚be剝in藏g若in響fo羨rm梅ed案co廈nt升ri重bu古te查t免o燒em久po雙we股rm績en忙t被of疤co俗ns碧um魚er翻s,尼a視s從on舅e被pa矛rt遙ic艘ip塑an避t巷st舊at曾es矛cl釘ea返rl蛇y:緞Th勸e村em妄po聯(lián)we纏rm敬en肺t腔of場th筑e銳co吃ns涂um幫er沿i玩s趟re蕉al膀ly便i傻mp賀or張ta疲nt公,柔I殖th按in擾k簡it虧's星課re丟al歐ly跑i忍mp尺or乖ta贈nt受th嬌at陶t農(nóng)he啊m縮en室ta來l叛he斤al才th亂s斷er依vi寸ce淚s比st卸af溫f狀gi謀ve堤c彼on跑su上me治rs他t導(dǎo)he能f辣ul明le鞋st紀i懇nf鄙or腹ma躺ti茅on朽po鑼ss渡ib竊le攻a破bo教ut巾t催re績at非me開nt麻,諸ab巾ou損t料di秀ag拼no脊si迷s,減a饞bo迫ut椅p剪ro高gn掘os住is脂,列ab賢ou駕t款ho朱w竄lo魂ng鬧t木he饞y'幫re濁l吐ik釀el捆y柿to能b鐮e癥on皆m尾ed久ic園at飽io鳥n,棄ab銜ou探t縮ho呈w襯lo扣ng惱t切he理y'蠟re咽l注ik燙el閱y仇to撐b余e菌in車th航e之se退rv末ic臉e.繳..方(智Pa喘rt賓ic牌ip系an墻t名7)稍.罰Ed痰uc頃at究io亮n殘of伍b伐ot背h脊st江af寬f/兇pr拼of肝es箭si就on親al陸s卵an他d進co獲mm牢un活it旗y索al副so論f吃al驕l課wi世th晨in白t紡hi靜s令th擾em茄e.濾M寫os彈t羞fr馬eq度ue贏nt底ly俗,塌pa艘rt滋ic挨ip里an餃ts恐'馳su私gg腫es獵ti蛙on丑s役of報a忘re壽as慶w貝he謝re喜e傲du紫ca明ti鑼on度is鉗n棚ee惑de退d,需f扇or朋b逮ot柏h版st褲af盟f郵an蓋d端th號e欲ge毀ne載ra抄l襯co梨mm突un細it栽y,封i浴s棵in禿u紋nd杰er理st荒an怎di告ng貿(mào)w溝ha激t刪it層i尸s畏li辨ke超t梨o期ex債pe黃ri頌en支ce朽a再m午en莖ta億l獻il譯ln平es灑s.尋Re膝la卷te材d掛to貞s勇ta燭ff榆e艱du統(tǒng)ca必ti搏on衛(wèi)i錢s墾th限e撿im富pl劍ic包at逢io倡n污th鑰at悼s螞ta麗ff閃k果no授wl東ed府ge游a快nd障e耕xp灘er怒ti鈴se墳af跨fe員ct綱s篩co餃ns蛾um特er卵s'幫e凱xp祖er侄ie削nc垂es哪.睛So膛me夸p警ar悼ti葬ci姜pa加nt蓋s迫ma躬de館r爹ef錯er鞠en輩ce考t扯o籃th皆e臺le牲ve肉l徒of淹e勞xp之er愛ti皆se弦o茫r叉kn匪ow榨le廈dg墾e械me絹nt釋al收h碼ea圖lt喂h熟st夾af健f割ha沒d.刊A港n劈as裝pe看ct旗o鄭f悅co餃mm普un懇it捉y(tǒng)器ed零uc蟻at室io碼n續(xù)re賢la輕te企s月sp息ec仔if片ic鴉al炕ly度to豈t袍ha榮t學(xué)of喉贏ca便re撐er膛s晶a辜nd裳f貪am踏il桌y拔me揭mb槐er讀s,深an矮d飄ho逢w原se見rv站ic畝es繞c敬an精k躬ee龜p塘th棕em筍in出fo吃rm城ed春a離nd筍e帖du種ca默te賢d.魚A議s拼th鈴e炒th區(qū)em請e率"R作el阿at越io葛ns晌hi搖ps否w胸it奴h納Co柿mm援un而it紙y"香i炊nd馳ic售at景es前,炎re山la池ti偶on泥sh設(shè)ip觸s罩wi嫌th弱f丘am店il店y法ar合e床cr馬uc攏ia雷l還fo篇r爪ma徒ny屋p找ar腫ti祝ci忘pa贏nt尚s.PowerandPowerlessnessThethemeofpowerandpowerlessnessrunsthroughthediscussionsofparticipants,connectingtomanyoftheotherthemesidentifiedinthetranscripts.Thisthemerelatestoapersonalsenseofhavingpowerorcontrol,ornot.Mostfrequentlyitisthepowerlessnesssideofthethemerepresented.Attimespowerlessnessisdiscussedinthecontextofstrugglingwithexperiencingsymptoms,orlivingwithamentalillness.However,thethemeisalsoreflectedinparticipants'storiesofstrugglingwiththehealthsystem,whichrunsthroughmuchofparticipants'discussionsaboutallaspectsoftheirexperienceswithservices.Oneparticipantsays:WhenIwasadmitted...thatwaspowerless,youwerepartofit,anumberthatwasliningup,yousleptinadormitory,youhadnofreedomoutside,andyouwereprettyheavilydrugged,sothat'spowerless,youwereprettymuchunder...thethumb.(Participant12).Anotherparticipantspokeaboutbeinginhospital,wheredoctorsaretheexpertsandhavethebalanceofpowertomakedecisions,toevenchoosewhetherconsumersareheardornot:Well,firstofallthepsychiatristsdonotlisten...themedicationhadthemostintolerablesideeffects...themedicationmadeitimpossibletolive(Participant18).Althoughlessfrequent,someparticipantsidentifyafeelingofpower,forexampleoneparticipantsays:WhenIdidthisconsumereducationcourse,Ifoundout,youdohaverights...didbecomeempoweredbyallthisstuff,becauseIgotemployment...theyhadaconsumersupportmeeting...andtheyemployedmetorunthemeeting...andIwasalsogettinginvolvedinmyownarea,goingtomeetingsandthings(Participant21).Thisparticipantgoesontodescribeherselfas"anempoweredconsumer"intheconversationlateron.Oneofthestrikingdifferencesbetweendiscussionoffeelingpowerlessversusfeelingpowerfulbytheseparticipantsisthatasenseofpowerlessnessissofrequentlyconnectedtothemannerinwhichservicesoperate,andhowstaffandothercommunitymembersinteractwithconsumers.However,whereparticipantsspokeaboutfeelingasenseofpower,moreoftenthisreflectedapersonalachievementorajourneythathadlittletodowithservices—indeedattimesitwasdespitedisempoweringexperienceswithservices.ConsumerinvolvementThisthemecapturestheexpresseddesirebyconsumerstobeincludedinallaspectsofmentalhealthserviceprovision.Amotifwithintheconversationsistheneedformoreconsumerinvolvement,atalllevels.Anaspectofthisisthesensethatservicesarestillfrequentlyresistanttogreaterconsumerinvolvement.Whilenotalwaysexplicitlystated,oneparticipantsummarizesclearlywhatseemstobetheunderlyingreasoningbehindthethemeofconsumerinvolvement:Ithinkit'sveryimportantbecausetheyaretheonesthathavethein-depthinformation...abouttheirownexperiencesandtheycanhelpotherpeoplethathaveexperiencedit...(Participant26).Participantsfrequentlyexpressconcernforotherconsumers,andtheimportanceoftheirknowledgebeingshared.Thepositiveimpactthatinvolvementhasforthempersonally,andthemutualityofconsumerinvolvementarediscussedbyparticipants,andseveralexplicitlylinkconsumerinvolvementinservicestocreatingasenseofhopeforconsumers.MedicationThisthemerelatestodiscussionofmedicationbyparticipants,representingtheimportancemedicationplaysformanyparticipantsintheirexperienceswithservices,andtheirpersonalexperiencesofillnessandrecovery.Frequentlyparticipantsdiscussthenegativeaspectofsideeffectsofmedication,andtheimportanceoffindingamedicationthatworksforthem.Connectingstronglywiththethemesof"relationshipswithstaffand"powerandpowerlessness"isthesub-themeofprofessionalsworkingwithmeregardingmedication.Severalparticipantshighlightedtherelationshipwithprofessionalsaroundmedicationissues.Forsomeparticipants,animportantfeatureoffindingamedicationthatworkedforthemwashavingprofessionalswholistenedtotheiropinion,whoworkedwiththem,ratherthanoverthemtofindmedicationthatworked:Ididhaveagooddoctor—whentherecomesatimewhereIsaid"I'dliketotrysomethingelse"...thedoctor'squitewillingtoletmeexperiment...and[I]endedupon[medicationname]whichworksquitewell...(Participant14).SystemIssuesThisthemerelatestonumerousissuesraisedintheinterviewsaboutservicesatasystemororganizationlevel.Subthemescapturedwithinthis,comprising"systemissues,"areoutlinedinTable1.Manyoftheserelatebacktoresourceissuesandfundingformentalhealthservicesbroadly,howeverallarehighlightedasrelevantandimportanttoconsumersoftheservices.Responsive/UnresponsivetoConsumersThisthemecapturesdiscussionswithininterviewsoftheneedforservicestoberesponsivetoconsumers:thatthepurposeofmentalhealthservicesistoserveconsumers.Atthecoreofthisthemeisthequestionofwhodecideswhatisneededforanyconsumer,howchoicesaremade,andwhoseneedsarebeingmetintheprocess.Forexample,someparticipantsdescribetheprocessofserviceshelpingtoidentifytheirneedsataparticulartime:They'dworkoutwhetherIneededtobeinhospitalorwhetherIjustneededtimeout.(Participant11).Otherparticipantshighlightedexperiences,wheredespitetheirsensethatservicesshouldbeaimingtobestaccommodateconsumers,oftenthiswasnotthecase:Thetimingofthings[is]becausestaffwanttodosomethingelse,andit'snotactuallyorientedtowardsconsumers.(Participant12).Whilesomeofthestoriesrelayedbyconsumersinourinterviewsrepresentexamplesofservicesbeingresponsivetothem,morestronglyconveyedisfrustrationatfindingservicesthatarenotresponsive.Forexample,oneparticipantspokeaboutbeinggiveninsufficientamountsofwatertotakemedicationandhavingtoaddressthis;participantsspokeaboutinformationbeingdisplayedininpatientunitsinpositionsthatwereinaccessible,particularlyforconsumerswhosevisionmaybeaffectedbymedication.RelationshipswithStaffRelationshipsareanimportantaspectofparticipants'discussions,andhowthesearefacilitated,ornot,bymentalhealthservices.Relationshipswithstaffappeartobecentraltomanyconsumers'experiencesoftheservices.Goodandbadattitudesofstaffwerediscussed;however,therewasapredominanceofnegativeattitudesinparticipants'stories.Oneparticipantdescribeshowunusualshefoundit,tofindastaffmemberwhoshowedpersonalinterest,andusesanindustrialmetaphortodescribeherfeelingofbeinga"pipe"inaproductionline,whenstaffinteractedwithher.Thisseemsreflectiveofmanyoftheconsumers'discussions.Participantsspokeaboutdoctorsbeing"crankyatmeattakingupthebedandthetime"inhospital(Participant1).Despitethepredominanceofstoriesaboutmorenegativestaffattitudes,somestoriestalkaboutpositiveattitudes:staffbeing"verysupportive—andtheydofollowupifyouneed...followupcare,theywillseeyoueverydayifyouwantthemto."(Participant16).Whetherparticipantsspeakaboutexperiencingpositiveornegativestaffattitudes,itisclearfromthesediscussionsthatstaffattitudesareintegraltotheirexperienceofanyservice.RelationshipswithTheirCommunityRelationshipswiththeircommunitiesarehighlightedasrelevanttoconsumers,withpeoplediscussingthegeneral,broadcommunityaswellasspecificrelationshipswithfamily,andotherconsumers.Participantsintheseinterviewsindicatethroughtheirconversationsthatpartoftheroleofservicesistofacilitatethesethreeareasofrelationships—eachbeingimportanttotheirexperiencesandrecovery.Relationshipswiththeircommunitiescanbecapturedinthesub-themeofisolationandcommunity.Thissubthemecapturesthedualaspectsofconnectedness:asenseofisolationandasenseofcommunity.Thisthemeweavesinandoutofparticipant'sdiscussions,connectingwithmanyoftheotherthemesidentified.Avarietyofaspectsofisolationandcommunityareraisedwithinthediscussions—asbeingafeatureofanillness,somethingyoucreateforyourself,somethingthecommunitydoestoyou,andaresultofinteractingwithservicesthemselves.Connectingwiththeircommunityalsotakesvariedformsfortheparticipants.Forsome,isolationisovercomewithinmentalhealthservices,particularlythroughcontactwithotherconsumers;othersdiscusstheimportanceofcontactwithotherpartsofthebroadercommunityandtheirfamily.Asoneparticipantsays,connectingwiththebroadercommunitywasimportantforher,"ratherthanjustbeinginthismentalhealthtunnel"(Participant16).Participantsintheinterviewsdiscussabroadrangeofexperienceswithisolationandfeelingasenseofcommunity,howeveroneoftheclearmessageswithinthediscussionsisthatformostparticipants,asenseofcommunity—connectedness—isimportanttotheirrecovery,andmentalhealth.Asoneparticipantsays:"ourenemyisisolation"while"friendshipisthekeytomentalhealth"(Participant17).Impliedisthatservicesneedtoaccommodatethis,andfacilitateconnectednessinitsvarietyofforms,bothwithinandbeyondservices.AllofMeThisthemewaslabeled"allofme"tocapturethesenseofpersonbeyondmentalillness,andspecificdiagnosis,conveyedbyparticipantsintheinterviews:inotherwordsthewholeperson.Severalsub-themesmakeupthisoverallthemeandcanbeseeninTable1.Eachofthesub-themesindicatesadifferentaspectofthewholeself,discussedbyparticipantsintheinterviews,togetheraccumulatingtorepresentanexpressionthatmentalhealthservicesshouldbedealingwitheachpersonasbroaderthantheirdiagnosisand/orillness.DiagnosisThisthemecapturesparticipants'discussionsaboutdiagnosisandtherolethishasplayedintheirexperienceswithmentalhealthservices.Severalparticipantsspokeabouttheirfrustrationwithnotbeingdiagnosed,orwithcontinualre-diagnosis.Participantsalsospokeaboutthedifficultytomovebeyondadiagnosisgiven,withintheservice,indicatingthattheirexperienceshavedemonstratedthatotherstafftheyencounterremaintiedtothediagnosisthey'vereceived—evenwhentheirsymptomsandexperiencesdonotfitthisdiagnosis.DiscussionandConclusionsAspolicyandliteraturerelevanttoevaluationinmentalhealthservicesindicates,consumers'viewsshouldbecentraltoevaluationofservices(CommonwealthofAustralia,1997;DepartmentofHealth,London,1999;USDepartmentofHealthandHumanServices,2001).Thethemespresentedhereprovidedeeperunderstandingaboutthebroadrangeofissuesimportanttoconsumersintheirinteractionswithpublicmentalhealthservices,importantinformationinitsownright,butadditionally,essentialtodevelopmentofmoreconsumerdrivenapproachestoserviceevaluationandadequatementalhealthresearch(Rapp,Shera&Kisthardt,1993).Oneofthemorecommonapproachestoincludingconsumers'viewsinmentalhealthserviceevaluationhasbeentheconsumersatisfactionsurvey(Clarke,2000).Consumersatisfactionsurveys,however,havebeencriticizedasbeingtokenisticattemptstoincludeconsumers'views,astheyfrequentlyaskquestionsbasedonprofessionals'viewsofwhatisimportantinservices,notconsumers'(Perkins,2001;Campbell,1997),andsofacethecorrespondingproblemofconsistentlyhighsatisfactionfindings,whichdonotrepresentmanyconsumers'realitieswithservices(Clark,Scott,Boydell&Goering,1999).Toolsthatdonotindicateareasneedingchange,orofdissatisfactiontoconsumers,arenotusefulinguidingorganizationalchange,centraltomodernevaluation(Guba&Lincoln,1989).Whilemorecontemporarymeasuresappearmorefrequentlytoincludeconsumers,tosomeleveleitherinitemdevelopment,usuallyviafocusgroups(Spear,2003;Meehan,Bergen,&Stedman,2002;Howardetal.,2001)orinitemrefinement(Eisenetal.,1999),comparisonoftheissuesdealtwithbythesetoolswiththethemesoutlinedhereindicatesthatthesemeasuresdonotcovertherangeofthemesparticipantsspokeaboutinourinterviews.Eachofthesemeasuresrevolvesaroundaslightlydifferentgroupingofissues,overlap-pingwiththethemesreportedhere,howevernotoneindividualquestionnaire,northesemeasuresincollection,openareascorrespondingtothethemes