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Although there is increasing recognition of the existence of 'difficult' patients who present particular challenges to mental health nurses, no research has been conducted into their perceptions of services and their experiences of care. This study identifies mental health service users who are defined by nurses as 'difficult' and explores their perceptions of their care experience. The results support earlier studies which suggested that 'difficult' patients challenge nurses' competence and control: despite their different roles both nurses and 'difficult' patients were aware of the struggle to gain or retain a notion of control. Respondents were able to identify the qualities of nurses and nursing interventions which had a positive effect on their care experience. Where nurses were perceived to demonstrate respect, time, skilled care and a willingness to give patients some control and choice in their own care, feelings of anger were reduced. These findings are discussed within the conceptual framework of 'power over' and 'power to' and implications for practice and research are considered.

Whilst current mental health care provision has made a substantial move towards empowering its users it retains a paternalistic approach with legislation such as 'supervised discharge'. This apparent paradox creates potential dilemmas for the mental health nurse and suggests there is a need for critical analysis of the justification for paternalism within mental health care. This paper discusses the conflict between the ethical principles of autonomy and beneficence which paternalism invokes. On reviewing the ethical theories of deontology and utilitarianism it appears that a prerequisite for autonomy is rationality, the absence of which provides justification of 'weak' paternalism. However, this paper contends that the assessment of rationality has the potential to be subjective and value laden. The use of competency tests can also be problematic by masking the essential ethical dilemma that is intrinsic to such assessment. A case study is used to illustrate the strengths and weaknesses of the competing arguments. This leads to the conclusion that whilst there may be some situations when the use of paternalism can be justified in mental health care, it should be exercised with caution. When there is disagreement between nurse and patient on what is considered to be in the patient's best interests, it should not be assumed that the patient is wrong or irrational.

Although rehabilitation literature frequently refers to recovery as the ultimate goal of therapeutic interventions, what recovery actually means is not clearly explained. However, the recovery model has been widely discussed in the context of mental health services, and it has been suggested that this model may also be applied to services for people with other long-term health conditions. This article explores this suggestion further by examining the recovery model and its relationship to physical rehabilitation.

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