Oil and water or oil and vinegar? Evidence-based medicine meets recovery

The illness management and recovery program: a contribution to recovery-oriented secondary mental health services

BACKGROUND

In recent decades, mental health services have been challenged to offer evidence-based practices (EBPs) that are person-centered, human rights- and recovery-oriented. The Illness Management and Recovery (IMR) program aims to promote recovery and enhance individuals' ability to live well. Investigating the IMR program from the perspective of mental health practitioners is crucial to improve recovery-oriented care and optimize program delivery.

METHODS

This study aimed to develop knowledge whether IMR, as an EBP, can function as a recovery-oriented practice (ROP) within secondary mental health care services. Seven focus groups were conducted, each consisting of two to eight mental health practitioners with different professional backgrounds and experiences. Altogether, 36 practitioners from five mental health hospitals and district psychiatric centers in Norway participated. Reflexive thematic analysis was used to analyze the data.

RESULTS

The results show that IMR (a) actively facilitates the alignment of coping mechanisms with patients' lives, and (b) emphasizes a recovery-oriented approach in the delivery of services. Mental health practitioners perceive IMR as inherently recovery-oriented. Although ROPs and EBPs are often considered to function in opposition, to the practitioners in our study they were neither contradictory nor mutually exclusive but complementary and with the potential to bring out the best in each other to support patients' recovery processes.

CONCLUSION

IMR, as an evidence-based, recovery-oriented program, bridges psychiatry and mental health recovery. However, challenges arise from its illness-oriented approach and language, as well as its emphasis on individual recovery aspects. While IMR underscores the social aspects of recovery, it is essential to highlight the social, and societal factors in individuals' recovery processes within the program.

Recovery-oriented psychiatry: oxymoron or catalyst for change?

This Personal View provides a normative and conceptual analysis of the intersection between the recovery movement and psychiatry. Although recovery emerged as a grassroots social justice movement emphasising empowerment and systemic change, psychiatry remains rooted in the medical paradigm. We aim to develop a nuanced conceptual framework that fosters academic debate and meaningful implementation, while avoiding superficial or tokenistic adoption of recovery principles. Our analysis explores the contrasting values, ontologies, and epistemologies of these perspectives, identifying points of tension and areas of compatibility. We examine and discuss integrative and non-integrative pluralistic approaches, and we conclude with actionable recommendations for transformation at different organisational levels.

REWRITALIZE your recovery: a study protocol for a randomised controlled trial (RCT) examining the effectiveness of the new recovery-oriented creative writing group intervention REWRITALIZE for people with severe mental illness

BACKGROUND

Health institutions advocate for psychosocial and recovery-oriented interventions alongside pharmacological treatment for severe mental illness. Participatory arts interventions appear promising in promoting personal recovery by fostering connectedness, hope, renegotiation of identity, meaning-making, and empowerment. Despite encouraging findings, however, the evidence base remains thin. Further, results from cognitive literature studies suggest possible impact on parameters of clinical recovery, but this has not been studied in clinical contexts. We developed REWRITALIZE, a structured, recovery-oriented, fifteen-session creative writing group intervention led by a professional author alongside a mental health professional. Participants engage with literary forms, write on them, share their texts, and partake in reflective discussions within a supportive, non-stigmatising environment, designed to promote self-expression, playful experimentation, agency, recognition, participatory meaning-making, renegotiation of identity and social engagement. The aim of this project is to evaluate REWRITALIZE for persons with severe mental illness through a randomised controlled trial (RCT) focusing on personal recovery outcomes. Additionally, an embedded pilot RCT will explore additional outcomes i.e., clinical recovery for a subgroup with schizophrenia spectrum disorders.

METHODS

The RCT is an investigator-initiated, randomised, two-arm, assessor-blinded, multi-center, waiting-list superiority trial involving 300 participants (age > 18) from six psychiatric centers in regions Capital and Zealand in Denmark, randomised to receive either the creative writing intervention combined with standard treatment or standard treatment alone. Assessments will be conducted before and after the intervention and at six months post intervention. The primary outcome is personal recovery at the end of intervention measured with the questionnaire of the process of recovery. Secondary outcomes include other measures of personal recovery, self-efficacy, mentalising, and quality of life. The pilot RCT, integrated within the RCT, will focus on 70 of the participants aged 18-35 with schizophrenia spectrum disorders, evaluating exploratory measures related to perspective-taking, social cognition, cognitive function, psychosocial functioning, and symptom pressure.

DISCUSSION

This is the first RCT for creative writing groups. It assesses whether REWRITALIZE, as adjunct to standard mental healthcare, is more effective for personal recovery than standard care. If successful, it would provide evidence for the efficacy of REWRITALIZE, potentially enabling its implementation across mental health centers in Denmark.

TRIAL REGISTRATION

Privacy (data protection agency): p-2023-14655. Danish National Center for Ethics: 2313949.

CLINICALTRIALS

gov: NCT06251908. Registration date 02.02.2024.

Making Sense of Recovery From First Psychosis With Antipsychotic Medication: A Qualitative Phenomenological Study

BACKGROUND AND HYPOTHESIS

Recovering from a first psychosis is a highly individual process and requires the person to make sense of their experiences. Clinicians, in turn, need to comprehend these first-person perspectives, creating a mutual sense-making dynamic. Antipsychotic medication is a substantial part of psychosis treatment. Providing insight in the lived experience of recovery with antipsychotics could improve the mutual understanding and help bridge the gap between the perspective of the clinician and that of the person recovering from psychosis.

STUDY DESIGN

14 persons in recovery from a first psychosis with the use of antipsychotics were interviewed. Their narratives were analyzed using Interpretative Phenomenological Analysis (IPA).

STUDY RESULTS

Five overarching themes were found, representing important and meaningful experiences in recovering with antipsychotic medication. Theme 1: antipsychotics as external dampening (4 subthemes); Theme 2: shifting of realities; Theme 3: pace of recovery; Theme 4: antipsychotics' influence on identity; and Theme 5: is it truly the antipsychotics?

CONCLUSIONS

Our findings show that recovery from psychosis with antipsychotics is an all-encompassing, multi-faceted, and ambivalent experience. The themes found in this research could inspire clinicians to discuss less obvious aspects of the experience of recovering with antipsychotics. Even more so, paying attention to the first-person perspective could lead to a more thorough understanding and benefit therapeutic relationships.

Health and Social Case Management for the Inclusion of People Living with a Schizophrenic Disorder: The PASSVers Experience

The way the social protection system in France is organized frequently leads to coordination difficulties between the social and healthcare sectors. A health and social program has been implemented in a French medical-psychological center to optimize the coherence of the pathway for people living with schizophrenia. This study evaluated the way users and professionals perceive this program so as to assess the relevance of double case management. Semi-structured interviews were conducted with users (N = 21) and professionals (N = 11) of this program and then analyzed with Alceste software. The results highlight the overall satisfaction of the participants with the program, and the double case management was shown to be beneficial in supporting people living with schizophrenia in their life project. These results indicate that this program enabled the emergence of a collective empowerment, which could assist with the recovery process of schizophrenia.

Mental health and human rights: Challenges for health services and communities

The care of people with mental health problems requires health system and service reforms to build up proper mental health care. The challenges of the present moment continue to be immense. The viral pandemic that we are experiencing has exposed the fragility of our health and social services and certified the inequality and precariousness of the living conditions of many people. The collection of articles published in the journal Salud Colectiva as part of the open call for papers "Mental health and human rights: challenges for health services and communities," includes articles from Spain, Brazil, Mexico, and Chile. These papers present conceptual experiences and reflections on community action plans and programs, contributing toward better knowledge and development of mental health in the region.

The recovery model in chronic mental health: A community-based investigation of social identity processes

The recovery model has been enormously influential in shaping mental health services globally over the last two decades. However, empirical research on its outcomes and psychological mechanisms is sparse. This community-based case study utilised both semi-structured qualitative interviews and quantitative survey methods to investigate perceptions of recovery, identity, and wellbeing among people with chronic and severe mental illness attending recovery-oriented support groups. Consistent with a social identity approach and the recovery model, to the extent that people identified as "in recovery", they reported better recovery outcomes (e.g., sense of purpose) and reduced psychological distress. Furthermore, recovery identity more strongly predicted recovery outcomes than it did psychological distress. Both the quantitative and qualitative data pointed to collective efficacy (i.e., group-based empowerment) as a key mediator of these outcomes. These findings are consistent with the recovery model and speak to the utility of a social identity approach for conceptualizing its efficacy. However, these findings also speak to the need for further evaluation of how and when recovery-oriented mental health services achieve their intended goal of improving quality of life for people with chronic and severe mental illness.

Sexuality and intimacy among people with serious mental illness: a qualitative systematic review

OBJECTIVE

The aim of this systematic review was to synthesize the best available qualitative evidence on the experiences and support needs of people with serious mental illness (SMI) regarding sexuality and intimacy within hospital and community settings. The objectives were to explore intimate relationship experiences of people with SMI, to uncover potential obstacles to the expression of sexuality and to present recommendations for mental health policy, education, research and practice.

INTRODUCTION

Mental health services worldwide have seen major transformations in recent years through deinstitutionalization programs and more enlightened ways of organizing and providing mental health care. However, in terms of social and emotional wellbeing, issues persist for people with SMI, particularly relating to intimacy and the expression of sexuality. This systematic review may assist service providers to determine ways that they may better support people in establishing and maintaining satisfying intimate relationships and the full expression of their sexuality.

INCLUSION CRITERIA

This review explored the intimacy and sexuality experiences, perceptions and concerns of people over the age of 18 years who were living with a SMI in hospital or community settings. This review considered studies that focused on qualitative data including, but not limited to, designs such as phenomenology, grounded theory, ethnography, action research and feminist research.

METHODS

The databases MEDLINE, CINAHL, PsycINFO, Embase and Web of Science were utilised in the review. The search included studies published from 1995 up to and including February 6, 2018 and were limited to those in the English language. Each paper was assessed by two independent reviewers for methodological quality using the Joanna Briggs Institute (JBI) Critical Appraisal Checklist for Qualitative Research. Any disagreements that arose between the reviewers were resolved through discussion. Data extraction was conducted by two independent reviewers using the standardized qualitative data extraction tool from JBI. The qualitative research findings were pooled using JBI methodology. The JBI process of meta-aggregation was used to identify categories and synthesized findings.

RESULTS

Based on the thematic findings from the 21 studies, three synthesized findings were extracted from 10 categories and 83 findings: 1) the complexity of individual sexual experiences, 2) the clinical constructs of sexuality and 3) family and partner involvement.

CONCLUSIONS

Having fulfilling and satisfying sexual and relationship experiences is a fundamental human right that can enhance an individual's quality of life. Being aware of the potential stresses and challenges that having a SMI can have on a relationship and involving partners in the treatment, may help to promote intimacy and recovery. Practitioners can use these findings to guide future policy, education and developments in practice. Further research is required to develop and evaluate interventions that target the identified barriers and help people with SMI to fulfil their unmet sexuality and intimacy needs.

Development and Validation of an Instrument to Measure Staff Perceptions of Recovery Climate and Culture in Mental Health Programs

OBJECTIVE

Few existing instruments measure recovery-oriented organizational climate and culture. This study developed, psychometrically assessed, and validated an instrument to measure recovery climate and culture.

METHODS

Organizational theory and an evidence-based conceptualization of mental health recovery guided instrument development. Items from existing instruments were reviewed and adapted, and new items were developed as needed. All items were rated by recovery experts. A 35-item instrument was pilot-tested and administered to a national sample of mental health staff in U.S. Department of Veterans Affairs Psychosocial Rehabilitation and Recovery Centers (PRRCs). Analysis entailed an exploratory factor analysis (EFA) and inter-item reliability and scale correlation assessment. Blinded site visits to four PRRCs were performed to validate the instrument.

RESULTS

The EFA determined a seven-factor solution for the data. The factors identified were staff expectations, values, leadership, rewards, policies, education and training, and quality improvement. Seven items did not meet retention criteria and were dropped from the final instrument. The instrument exhibited good internal consistency (Cronbach's α=0.81; subscales, α=0.84-0.88). Scale correlations were between 0.16 and 0.61, well below the threshold (α=0.9) for indicating overlapping constructs. Site visitors validated the instrument by correctly identifying high-scoring and low-scoring centers.

CONCLUSIONS

These findings provide a psychometrically tested and validated instrument for measuring recovery climate and culture in mental health programs. This instrument can be used in evaluation of mental health services to determine the extent to which programs possess the organizational precursors that drive recovery-oriented service delivery.

Towards community-based and recovery-oriented care for severe mental disorders in Southern and Eastern Europe: aims and design of a multi-country implementation and evaluation study (RECOVER-E)

BACKGROUND

Substantial strides have been made around the world in reforming mental health systems by shifting away from institutional care towards community-based services. Despite an extensive evidence base on what constitutes effective care for people with severe mental ill-health, many people in Europe do not have access to optimal mental health care. In an effort to consolidate previous efforts to improve community mental health care and support the complex transition from hospital-based to community-based care delivery, the RECOVER-E (LaRge-scalE implementation of COmmunity based mental health care for people with seVere and Enduring mental ill health in EuRopE) project aims to implement and evaluate multidisciplinary community mental health teams in five countries in Central and Eastern Europe. This paper provides a brief overview of the RECOVER-E project and its methods.

METHODS

Five implementation sites were selected (Sofia, Bulgaria; Zagreb, Croatia; Skopje, North Macedonia; Kotor, Montenegro; Siret-Suceava, Romania) where hospital-based mental health services are available (care as usual, CAU) for patients with severe mental disorders (severe depression, bipolar disorder, schizophrenia). The intervention consists of the introduction of a new service delivery model in each site, consisting of community-based recovery-oriented care delivered by trained multidisciplinary community mental health teams (including a peer worker with lived experience of a severe mental disorder). The implementation outcomes of the teams and the effect of the team's approach on patient and service utilisation outcomes will be evaluated using a mix of research methods. The study includes five planned hybrid implementation-effectiveness trials (1 per site) with patient-level randomization (n = 180, with patients randomised to either care as usual or intervention condition). Effectiveness is evaluated using a pragmatic non-blinded design with patients randomised into two parallel groups: receiving new community-based care or receiving usual care in the form of institutional, hospital-based mental health care. Trial-based health economic evaluation will be conducted; implementation outcomes will be evaluated, with data aligned with dimensions from the RE-AIM framework. Pathways to sustaining project results will be developed through policy dialogue sessions, which will be carried out in each country and through ongoing policy engagement activities at the European level.

DISCUSSION

The RECOVER-E project has been developed and conducted to demonstrate the impact of implementing an evidence-based service delivery model for people with severe mental illness in different contexts in middle-income countries in Central and Eastern Europe. It is expected that the results will contribute to the growing evidence-base on the health and economic benefits of recovery-oriented and community-based service models for health systems in transition.Trial registration Each trial was registered before participant enrolment in the clinicaltrials.gov database: Site-Croatia, Zagreb (Trial Reg. No. NCT03862209); Montenegro, Kotor (Trial Reg. No. NCT03837340); Romania, Suceava (Trial Reg. No. NCT03884933); Macedonia, Skopje (Trial Reg. No. NCT03892473); Bulgaria, Sofia (Trial Reg. No. NCT03922425).

Recovery for all in the community; position paper on principles and key elements of community-based mental health care

BACKGROUND

Service providers throughout Europe have identified the need to define how high-quality community-based mental health care looks to organize their own services and to inform governments, commissioners and funders. In 2016, representatives of mental health care service providers, networks, umbrella organizations and knowledge institutes in Europe came together to establish the European Community Mental Health Services Provider (EUCOMS) Network. This network developed a shared vision on the principles and key elements of community mental health care in different contexts. The result is a comprehensive consensus paper, of which this position paper is an outline. With this paper the network wants to contribute to the discussion on how to improve structures in mental healthcare, and to narrow the gap between evidence, policy and practice in Europe.

MAIN TEXT

The development of the consensus paper started with an expert workshop in April 2016. An assigned writing group representing the workshop participants built upon the outcomes of this meeting and developed the consensus paper with the input from 100 European counterparts through two additional work groups, and two structured feedback rounds via email. High quality community-based mental health care: 1) protects human rights; 2) has a public health focus; 3) supports service users in their recovery journey; 4) makes use of effective interventions based on evidence and client goals; 5) promotes a wide network of support in the community and; 6) makes use of peer expertise in service design and delivery. Each principle is illustrated with good practices from European service providers that are members of the EUCOMS Network.

CONCLUSIONS

Discussion among EUCOMS network members resulted in a blueprint for a regional model of integrated mental health care based upon six principles.

Working towards least restrictive environments in acute mental health wards in the context of locked door policy and practice

There has been a shift towards provision of mental health care in community-based settings in Australia. However, hospitals continue to care for people in acute mental health wards. An increasing proportion of the people in wards are admitted involuntarily, subject to restrictions of movement to minimize risk of harm to self and others. In response to concerns about the safety of people absconding from care, Queensland Health introduced a policy requiring all acute mental health wards in the State to be locked. In response, the Queensland Mental Health Commission funded a project to understand the impact of this policy and develop evidence-based recommendations regarding provision of least restrictive, recovery-oriented practices in acute wards. Facilitated forums were conducted with 35 purposively selected participants who identified as consumers, carers, or staff of acute mental health hospital wards, to test the acceptability, feasibility, and face validity of a set of evidence-informed recommendations for providing least restrictive, recovery-oriented practices. Participant responses were recorded, and data were analysed through an inductive, thematic approach. A recovery-oriented approach was supported by all stakeholders. Reducing boredom and increasing availability of peer support workers were considered key to achieving this. Focusing less on risk aversion was reported as central to enabling true Recovery Orientation. This project enabled recognition of the perspectives of consumers, carers, and staff in the consideration of evidence-informed recommendations that could be implemented to provide least restrictive care in the context of locked doors.

Changing practice using recovery-focused care in acute mental health settings to reduce aggression: A qualitative study

Consumer aggression is common in acute mental health settings and can result in direct or vicarious psychological or physical impacts for both consumers and health professionals. Using recovery-focused care, nurses can implement a range of strategies to reduce aggression and empower consumers to self-regulate their behaviour, when faced with challenging situations, such as admission to the acute care setting. Currently, there is limited literature to direct nurses in the use of recovery-focused care and how it can be used to reduce consumer aggression. Twenty-seven mental health nurses participated in this study. The constructivist grounded theory method guided data collection and analysis to identify categories that accurately described participants' experiences. Five categories emerged that described how nurses can implement recovery-focused care clinically to reduce the risk of consumer aggression: (i) identify the reason for the behaviour before responding; (ii) being sensitive to the consumer's trigger for aggression; (iii) focus on the consumer's strengths and support, not risks; (iv) being attentive to the consumer's needs; and (v) reconceptualize aggression as a learning opportunity. As the importance of promoting consumer recovery is now embedded in mental health policies internationally, nurses need to prioritize the application of recovery-focused care clinically. Further research to provide evidence-based outcomes supporting the use of recovery-focused care is needed.

Dilemmas in recovery-oriented practice to support people with co-occurring mental health and substance use disorders: a qualitative study of staff experiences in Norway

Background

Recovery-oriented practice is recommended in services for people with co-occurring mental health and substance use disorders. Understanding practitioners’ perceptions of recovery-oriented services may be a key component of implementing recovery principles in day-to-day practice. This study explores and describes staff experiences with dilemmas in recovery-oriented practice to support people with co-occurring disorders.

Methods

Three focus group interviews were carried out over the course of 2 years with practitioners in a Norwegian community mental health and addictions team that was committed to developing recovery-oriented services. Thematic analysis was applied to yield descriptions of staff experiences with dilemmas in recovery-oriented practice.

Results

Three dilemmas were described: (1) balancing mastery and helplessness, (2) balancing directiveness and a non-judgmental attitude, and (3) balancing total abstinence and the acceptance of substance use.

Conclusions

Innovative approaches to practice development that address the inherent dilemmas in recovery-oriented practice to support people with co-occurring disorders are called for.

Electronic supplementary material

The online version of this article (10.1186/s13033-018-0211-5) contains supplementary material, which is available to authorized users.

"What is the work of Recovery Oriented Practice? A systematic literature review"

Concepts of personal and social recovery in mental illness are constantly evolving because the journey is fluid and subject to change over time. Dynamic interactions between the complexities of human nature and mental illness create ever-altering landscapes of perplexity. The acknowledged ebb and flow of recovery in the presence of chronic and serious mental illness requires health professionals to provide a flexible suite of care, delivered through skills and methods that are responsive and meaningful to the recipient. We conducted a systematic search for qualitative literature that articulated the work of personally-supportive recovery-oriented practice (ROP) to determine the specific components of recovery-supportive work. Twenty-one articles were identified as meeting the inclusion criteria and were synthesized using a coding framework derived from Normalization Process Theory. We identified three kinds of recovery-supportive work required from health professionals: alleviating stigma, delivering effective recovery-supportive responses in the presence of complex health and social situations and managing challenges associated with the work of ROP. We discuss the resources needed for ROP and the barriers that inhibit health professionals' engagement in this work. By elucidating the work of ROP, we highlighted a disparity between health professionals' aspirations and achievements. These revelations could inform service delivery in order to better support consumer recovery in serious mental illness.

Validity of clinically significant change classifications yielded by Jacobson-Truax and Hageman-Arrindell methods

BACKGROUND

Reporting of the clinical significance of observed changes is recommended when publishing mental health treatment outcome studies and is increasingly used in routine outcomes monitoring systems. Since recovery rates vary with the method chosen, we investigated the validity of classifications of clinically significant change when the Jacobson-Truax method and the Hageman-Arrindell method were used.

METHODS

Of 718 inpatients who completed the Depression Anxiety Stress Scales (DASS-21) and Quality of Life Enjoyment and Satisfaction Questionnaire at admission and discharge to a psychiatric clinic, 355 were invited (and 119 agreed) to complete the questionnaires and the Recovery Assessment Scale six weeks post discharge.

RESULTS

Both the JT and HA methods showed comparably good validity when referenced against the other indices. Clinically significant change on the DASS-21 was related to a greater consumer-based sense of recovery, greater perceived quality of life, and fewer readmissions to hospital within 28 days of discharge.

CONCLUSIONS

Since there was found to be no advantage to using one method over another when recovery is of interest, the simpler JT method is recommended for routine usage.

Recovery in Schizophrenia: What Consumers Know and Do Not Know

The recovery model has permeated mental health systems by leading to the development of new psychiatric interventions and services and the reconfiguration of traditional ones. There is growing evidence that these interventions and services confer benefits in clinical and recovery-oriented outcomes. Despite the seeming adoption of recovery by policy makers, the transformation of mental health systems into recovery-oriented systems has been fraught with challenges.

Recovery, as Experienced by Women with Borderline Personality Disorder

Studies examining recovery through the service users' perspectives have mainly included persons with schizophrenia or bipolar disorder. Giving voice to those with borderline personality disorder (BPD) would enrich our understanding of recovery, as their specific experiences may bring new dimensions, obstacles and facilitators. The objective of this study was to qualitatively capture the experience of recovery in women with BPD. Participants were women between 18 and 65 years old who had a diagnosis of BPD and completed at least 2 years in a program for persons with BPD. During the first meeting, they produced a picture collage, followed by an interview on their experience of recovery. The second meeting was a phone interview to discuss new thoughts. In addition, their medical records were reviewed. A thematic analysis of the interviews was conducted and organized with the Person-Environment-Occupation model. Although recovery was not the best term to name their experience, they all talked about a process towards stability and wellbeing (n = 12). Dimensions of recovery included, for example, letting go of the past (person), being involved in meaningful activities (occupation) and having healthy relationships (environment). Facilitators included social support and participation in a specialized therapy program. The main obstacle was unstable family relationships. The findings from this study showed similar dimensions to previous recovery studies, new perspectives on certain dimensions, as well as new ones. They also reinforced the importance to incorporate intervention outcomes that target the person with BPD, their social environment and meaningful occupations.

Supporting Recovery Orientated Services for People With Severe Mental Illness

There is now wide agreement that people with severe mental illness can be adequately treated and cared for in the community, provided back-up hospital care is available when needed. Another important development has been the recognition that clinical treatment and care is insufficient for recovery and restoration of role functioning following illness onset, and must be supplemented by evidence-based practices in psychiatric rehabilitation. This article describes how allied health professionals can lead recovery oriented approaches that incorporate evidence-based forms of psychiatric rehabilitation. Family psychoeducation and supported employment are provided as examples of such evidence-based practices that require wider implementation.

The professional experiences of peer specialists in the Georgia Mental Health Consumer Network

There has been an increase in the number of peer-led services within the mental health care system. There however remains little information about the experiences of peers serving in such helping roles. This study explored the professional experiences of peer specialists including the basic roles, benefits, and potential challenges of the peer specialist role. Peer specialists (N = 84) completed a battery of surveys and questionnaires. Qualitative analysis of participants' responses indicated that peer specialists face difficulties such as poor compensation, limited employment opportunities, work stress, emotional stress in helping others, and maintaining personal wellness. Quantitative analyses revealed that recovery attitudes may confer clinical and psychosocial benefits for peer specialists and employment may contribute to hope, empowerment, social engagement, and competence. Peer specialists would benefit from resources and supports aimed at their continued training and supervision. Fostering the vocational advancement of peer specialists could potentially enhance their experiential recovery and community functioning.

Psychosocial well-being construct in people with severe mental disorders enrolled in supported employment programs

The main purpose of this prospective study is to validate the construct of psychosocial well-being (PSWB) for people with severe mental disorders enrolled in Supported Employment (SE) programs. This paper also aims to assess the impact of job acquisition on PSWB after obtaining competitive employment. A two-phase study approach was used and 231 individuals with severe mental disorders enrolled in SE programs who took part in both phases. The shortened versions of the Psychological Well-Being Scale (Keyes et al. in J Personal Soc Psychol, 82(6):1007-1022, 2002; Ryff and Keyes in J Personal Soc Psychol 69(4):719-727, 1995) and the Social Well-Being Scale (Keyes in Soc Psychol Q 61(2):121-140, 1998) were used. The PSWB's multidimensionality construct was confirmed. The results of repeated measure ANOVA analyses revealed that job acquisition, as well as, being involved in a work-seeking process increase the PSWB of people with severe mental disorders. Employment specialists might find clinical utility in using this validated tool for assessing PSWB in their clients with severe mental disorders. In a recovery oriented approach to psychiatric services and SE programs, clinicians and employment specialists should continue to encourage their clients in their work integration process even though they may not all obtain competitive employment quickly.

[Autonomous Medication Management: an analytical intervention in mental health care services]

In a context of high rates of medicalization of the population and in light of the scantly critical use of psychiatric medications in mental health services, this paper reports aspects of a qualitative study that had the opportunity to intervene in care practices in three major Brazilian cities. Following the principle of Brazilian Psychiatric Reform championing users' rights to participate in decisions about their treatment, the research intervened in psychosocial care centers (CAPS) seeking the empowerment of the users regarding the use of drugs in their therapeutic projects. Interviews were conducted and focus groups set up. From this recorded material, the paper analyzed some situations that, among other things, attested to the difficulty of avoiding the exercise of power over users via the administration of psychotropic drugs. Little dialogue about drugs, and the existence of stigmatization spaces where user rights are inhibited or "accepted with caution," was also detected in the services surveyed.

Patient involvement in mental health care: one size does not fit all

BACKGROUND

Involvement of mental health-care patients in the decision-making processes is considered to be an ethical requirement. Health-care systems worldwide are increasingly emphasizing the value of participatory approaches. There is, however, no consensus on the definition of patient involvement. The literature is particularly inconsistent and lacks clarity.

OBJECTIVE

The purpose of this article is to clarify the concept of patient involvement in mental health care (MHC), taking into account its multidimensional nature.

SEARCH STRATEGY

We searched the literature in online databases from January 1998 until August 2010 using synonyms of 'patient involvement', combined with the terms 'mental health(care)'.

DATA SYNTHESIS

Based on 45 different descriptions found in the literature, we constructed a definition of patient involvement and we drew up a model identifying its determinants and outcomes.

RESULTS

We propose a comprehensive model of patient involvement to be used in MHC. This model can serve as a guide for policy makers and field workers to shape policies to stimulate involvement.

DISCUSSION AND CONCLUSIONS

There are three main problems in the literature concerning patient involvement. First, there is a proliferation of conceptualizations of the topic, leading to conceptual vagueness. Furthermore, there is a lack of quantitative data, and some aspects of involvement remain underexposed, such as the involvement of specific target groups and practical ways to shape the involvement processes. Involvement processes should be tailored to the specific target group and context.

Implementing cognitive remediation therapy: lessons from two public mental health services

OBJECTIVE

Neurocognitive deficits are a core symptom domain of schizophrenia, occurring in 75-90% of people with this diagnosis and influencing long term functional outcomes. This article aims to describe the pilot implementation of cognitive remediation therapy in two large public mental health services and detail changes made to the delivery of this therapy after this trial.

CONCLUSIONS

Cognitive remediation therapy provides an evidence-based approach to targeting cognitive deficits but the translation of this therapy from a research setting to clinical practice has not been well evaluated.

Consumer's perceptions of Recovery-oriented mental health services: an Australian case-study analysis

Recovery approaches to health care now feature in the mental health policies of many Western countries. There are, however, continuing challenges to the operationalization of these approaches. This study aimed to identify the nature of these challenges for a public mental health service organization located in a major urban center in southeastern Australia, where Recovery-oriented services have been implemented; and to develop recommendations to address these challenges. These aims were achieved by asking mental health consumers about their experiences of the implementation of Recovery-oriented services. Research participants described an uncertainty in health professionals and consumers alike about how to practice within a Recovery model, with many health professionals taking a "hands off" approach in the name of Recovery, rather than working in partnership with consumers and other stakeholders, including the community managed organizations. Solutions to these challenges included more targeted, practice-focused education for consumers and health professionals, with this education provided by consumer representatives. Insights derived from this research add to the growing body of evidence related to the implementation of Recovery-oriented services in Western countries.

Racial and Ethnic Cultural Factors in the Process of Acceptance of Mental Illness

Acceptance of mental illness is essential to promoting recovery and is uniquely impacted by issues of culture, race, and ethnicity. Qualitative case narrative methodology was used to identify themes related to the cultural facilitators and barriers in the acceptance process. Five participant narratives are presented to assist practitioners in applying these findings to rehabilitation counseling. Selected case narratives represent participants from diverse racial and ethnic backgrounds to illustrate cultural facilitators and barriers in the acceptance process. Implications are suggested for culturally responsive counseling and research pertaining to the process of acceptance of mental illness.

Recovery-oriented services for individuals with mental illness and case managers' experience of professional burnout

Present cross-sectional study examined perceptions of recovery-oriented services and reports of professional burnout and job satisfaction in a sample of 114 case managers working in community mental health centers across Ohio. The research examined the relative contribution of demographic characteristics, the structure of case management services, and case managers' beliefs about recovery-oriented services in describing their reports of professional burnout and job satisfaction. Regardless of individual characteristics of case managers and reports of the structure of their jobs, case managers who perceived their agency to offer higher levels of recovery-oriented services also reported lower levels of depersonalization and emotional exhaustion at work, and higher levels of professional accomplishment and job satisfaction. Directions for future research in the area are discussed.

Recovery in Canada: toward social equality

This article reviews evolution of the recovery paradigm in Canadian mental health. We first trace the origins and development of the recovery concept through the literature, followed by an examination of how the recovery concept has been implemented in national and provincial mental health policy since publication of the 2006 Kirby Commission Report. Based on consultations with Canadian policymakers, and an examination of available policy documents, we explore how the dual theme of 'recovery' and 'well-being', adopted by the Mental Health Commission of Canada in its 2009 strategy: Toward Recovery and Well-being - A Framework For a Mental Health Strategy has subsequently played out in mental health policymaking at the provincial level. Findings reveal mixed support for recovery as a guiding principle for mental health reform in Canada. While policies in some provinces reflect widespread support for recovery, and strong identification with the aspirations of the consumer movement; other provinces have shifted to population-based, wellness paradigms that privilege evidence-based services and professional expertise. The recognition of social equality for people who experience mental illness emerges as an important value in Canadian mental health policy, cutting across the conceptual divide between recovery and well-being.

[New parameters in community treatment practices: the contribution of community and alternative mental health groups in Québec]

This article examines the origin and the context of the implementation project of community treatment according to the perspective of community and alternative mental health groups in Québec. The author presents results of a research on practices of these groups through a specific array that integrates the essential components of the community treatment model. The author examines six parameters characterizing devices, approaches and practices: 1) approach in supportive care and attention; 2) voluntary relation with the organization 3) the place of biomedical treatment; 4) flexibility in length and intensity of treatment; 5) the individual and collective dimension of supportive care; 6) and, participation as an active citizen.

Economic approaches to improving access to evidence-based and recovery-oriented services for people with severe mental illness

During the past 3 decades, research has identified several psychosocial evidence-based practices (EBPs) for people with severe mental illness (SMI). Starting from a different origin, the recovery movement has influenced perceptions of how EBPs and other services should be delivered, and also emphasized the value of peer supports. We now know much more than 30 years ago about the kinds of services that help people with SMI live satisfying lives in the community. Evidence-based and recovery-oriented services require additional resources but use them sparingly: they are highly individualized, often result in reductions in costs of other mental health services, such as hospitalizations, and favour reliance on and integration into community settings rather than mental health services. Nevertheless, access to such services remains very limited. During the same period, the place of medications in the services system has become a source of growing concern, and there are several reasons to believe that current spending on medications is excessive. Inadequate housing and community supports that increase lengths of stay unnecessarily and spending on ineffective, nonrecovery-oriented vocational services are only 2 additional forms of misallocation of resources. Devolving control over medication budgets to regional or local health authorities, introducing program budgeting and marginal analysis, and implementing individual budgets to give more control to service users (in addition to promoting shared decision making) merit further investigation as potential strategies to improve outcomes for people with SMI in Canada in the context of limited budgets.

Recovery-promoting professional competencies: perspectives of mental health consumers, consumer-providers and providers

OBJECTIVES

The purpose of this study was to empirically validate a set of conceptually derived recovery-promoting competencies from the perspectives of mental health consumers, consumer-providers and providers.

METHODS

A national sample of 603 consumers, 153 consumer-providers and 239 providers completed an anonymous survey via the Internet. The survey evaluated respondents' perceptions about a set of 37 competencies hypothesized to enhance clients' hope and empowerment and inquired about interactions with providers that enhanced clients' recovery process. We used descriptive statistics and ranking to establish the relevance of each competency and generalized linear models and post-hoc tests to examine differences in the consumers', consumer-providers' and providers' assessments of these competencies.

RESULTS

Analyses confirmed the recovery relevance of several competencies and their relative importance within each group of study participants. They also revealed that while most competencies tended to have universal significance, others depended more strongly on the client's preferences. Finally, differences in the perceptions of consumers, consumer-providers and providers about the recovery relevance of these competencies were established.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

The study highlighted the crucial role practitioners play in enhancing recovery from serious mental illnesses through specific strategies and attitudes that acknowledge clients' personhood and foster their hopefulness, empowerment and illness management. It informed the development of a new instrument measuring providers' recovery-promoting competence and provides guidelines for sharpening the recovery focus of a wide range of mental health and rehabilitation services.

Schizophrenia, "just the facts" 5. Treatment and prevention. Past, present, and future

The introduction of second-generation antipsychotics and cognitive therapies for schizophrenia over the past two decades generated considerable optimism about possibilities for recovery. To what extent have these developments resulted in better outcomes for affected individuals? What is the current state of our science and how might we address the many unmet needs in the prevention and treatment of schizophrenia? We trace the evolution of various treatments for schizophrenia and summarize current knowledge about available pharmacological and psychosocial treatments. We consider the widely prevalent efficacy-effectiveness gap in the application of available treatments and note the significant variability in individual treatment response and outcome. We outline an individualized treatment approach which emphasizes careful monitoring and collaborative decision-making in the context of ongoing benefit-risk assessment. We note that the evolution of both pharmacological and psychosocial treatments thus far has been based principally on serendipity and intuition. In view of our improved understanding of the etiology and pathophysiology of schizophrenia, there is an opportunity to develop prevention strategies and treatments based on this enhanced knowledge. In this context, we discuss potential psychopathological treatment targets and enumerate current pharmacological and psychosocial development efforts directed at them. Considering the stages of schizophrenic illness, we review approaches to prevent progression from the pre-symptomatic high-risk to the prodrome to the initial psychotic phase to chronicity. In view of the heterogeneity of risk factors, we summarize approaches towards targeted prevention. We evaluate the potential contribution of pharmacogenomics and other biological markers in optimizing individual treatment and outcome in the future.