This study used a mixed methods approach to describe and analyze data from groups observed in two types of mental health consumer-centered programs, namely consumer-run drop-in centers and clubhouses. An overview of consumer-centered programs is presented, followed by a report of the study which includes a description of the groups in the sample and data on the effects of group process and group leader characteristics on group functioning. Results indicate that, for the most part, the groups were task oriented (e.g., planning events or discussing issues about the center). Psychoeducation and recovery were also frequent topics in the group meetings. In terms of group participation, consumers took on various assignments, served as facilitators, assumed tasks and roles, shared experiences, and provided support to other group participants. A major finding is that group leaders displayed both good and poor leadership behaviors. The good leadership behaviors were often efforts to respond to problematic responses of members and poor leadership behaviors often elicited such responses. The qualitative analysis provided examples of how these behaviors affected the group sessions. This pilot study, by identifying some of the group conditions present in such groups, should lead to new studies that are based on specific hypotheses concerning the relationships that exist among group conditions, interventions to improve such conditions, and outcomes for participants.
Spirituality has been cited in the literature as having a positive effect on mental health outcomes. This paper explores the relationship of spirituality to demographic, psychiatric illness history and psychological constructs for people with mental illness (N=1835) involved in consumer-centered services (CCS-Clubhouses and Consumer run drop-in centers). Descriptive statistics indicate that spirituality is important for at least two thirds of the members in the study. Members primarily indicated participation in public spiritual activities (i.e., church, bible study groups), followed by private activities (prayer, reading the bible, and meditation) (both of which were centered on belief in the transcendent). A logistic regression analysis was done to explore variables related to spirituality (i.e., demographics, psychiatric illness history, and psychological constructs). Results suggest that age, gender, having psychotic symptoms, having depressive symptoms, and having a higher global quality of life, hope and sense of community were all significant correlates of spirituality.
Located in a community mental health center, the first decision support center in psychiatry used peer support and an Internet-based software program, CommonGround, to assist consumers in decisional uncertainty about psychiatric medication use and to foster shared decision making between the consumer and prescriber. This study examined the impact of the decision support center on the consumer-doctor interaction in the medication consultation. A pretest/posttest design assigned consumers to either an experimental or control group for 4 months. The Measure of Patient-Centered Communication (MPCC) (Brown, Stewart, McCracken, McWhinney, & Levenstein, 1986) was used to evaluate the medication consultation. The Patient Perception of Patient-Centeredness Questionnaire (PPPC) (Stewart, Meredith, Ryan, & Brown, 2004) was used to evaluate the consumer's and prescriber's perceptions of the consultation. A one-way multivariate analysis of covariance was not significant for the combined dependent variable of the measures at Time 2, while controlling for the measures at Time 1. When the CommonGround report was referenced in the experimental group, post hoc analyses revealed significant differences (t[41] = 4.14, p =.001) in the PPCC-consumer score. This study provides provisional evidence of the effectiveness of a shared decision-making intervention. The clinical potential of a program that assists mental health consumers in communicating decisional uncertainty and developing shared decisions concerning medication use is worthy of further study.
Job development is critical to assisting people with serious disabilities to obtain jobs, but little is known about the actual methods that make job development effective. Using a post-only quasi-experimental design, this study examined the effects of the Conceptual Selling® method on the number of job development contacts and number of job placements. By controlling for employment specialists' characteristics (age, length of time in current position, years of human service experience, and years of business experience), the authors determined that the employment specialists trained in the Conceptual Selling® method had more job development contacts per employer, leading to more effective job placements for employers contacted, than the control group.
The Institute of Medicine ( 1 ) has found the quality chasm framework to be applicable to health care for people with mental health and substance use disorders, and it cites shared decision making as one of the top ten rules to guide the redesign of health care. Shared decision making has been defined as a collaborative process between a client and a practitioner, both of whom recognize one another as experts and work together to exchange information and clarify values in order to arrive at health care decisions ( 2 , 3 ).
Decision aids for practitioners and clients have been developed in general health care to support the shared decision-making process ( 4 ). Decision aids are particularly helpful in reducing decisional conflict associated with making challenging choices in which there are benefits and risks associated with treatment or when empirical evidence is inconclusive or incomplete ( 5 ). Deegan and Drake ( 6 ) have argued that shared decision making and the use of decision aids related to medication management in psychiatry is an ethical imperative, is consistent with the long-standing tradition of building therapeutic alliances in treatment collaboration, and is a superior approach to medical paternalism and insistence on medication compliance.
In this column, we describe a 12-month pilot program to begin to identify best practices for shared decision making in an outpatient psychiatric medication clinic. The primary intervention was the transformation of a typical waiting area in an urban, midwestern psychiatric medication clinic into a peer-run Decision Support Center (DSC). Services at the DSC included establishing peer-specialist protocols to support a welcoming environment, offering a healthy snack and beverage, assisting clients in completing a one-page computer-generated report for use in the medication consultation, giving clients access to health-related information via the Internet, providing informal peer support, and providing support with completing decision aids for helping clients address areas of decisional conflict related to medication use. Medication appointments were redefined to include 30 minutes of work in the DSC before meeting with a physician or nurse.
Objective: This study examined the positive effects on recovery outcomes for people with severe and persistent mental illness using peer-led groups based on Pathways to Recovery: A Strengths Recovery Self-Help Workbook (PTR). PTR translates the evidence-supported practice of the Strengths Model into a self-help approach, allowing users to identify and pursue life goals based on personal and environmental strengths. Methods: A single-group pretest-posttest research design was applied. Forty-seven members in 6 consumer-run organizations in one Midwestern state participated in a PTR peer-led group, completing a baseline survey before the group and again at the completion of the 12-week sessions. The Rosenberg Self-Esteem Scale, the General Self-Efficacy Scale, Multidimensional Scale of Perceived Social Support, the Spirituality Index of Well-Being, and the Modified Colorado Symptom Index were employed as recovery outcomes. Paired Hotelling's T-square test was conducted to examine the mean differences of recovery outcomes between the baseline and the completion of the group. Results: Findings revealed statistically significant improvements for PTR participants in self-esteem, self-efficacy, social support, spiritual well-being, and psychiatric symptoms. Conclusions: This initial research is promising for establishing PTR as an important tool for facilitating recovery using a peer-led group format. The provision of peer-led service has been emphasized as critical to integrating consumers' perspectives in recovery-based mental health services. Given the current federal funding stream for peer services, continued research into PTR and other peer-led services becomes more important. Copyright 2010 Trustees of Boston University.
This paper briefly reviews the recent history of psychosocial treatment for adults with severe mental illnesses in the United States. It examines the current sources and financing of such care, revealing the planned and unplanned reclassification of entitled beneficiaries and eligible patients, appropriate treatment, acceptable outcomes, and levels and sources of payment. One illustration of this phenomenon is seen in current efforts to identify and deliver only those public services that are covered by Medicaid, so as to allocate state resources only when they can be matched by federal monies. Another is the reliance on private health insurance, tied in the U.S. almost exclusively to employment, for medical care delivered under an acute, rather than a chronic care model. These analyses conclude with a discussion of the implicit and explicit mechanisms used to ration access to psychosocial treatment in the United States. The implications for individuals with serious mental illnesses, their families, and the general public are placed in historical and current policy contexts, recognizing the economic, social, and clinical variables that can moderate outcomes.
In-depth phone surveys were conducted with 32 consumer-run drop-in centers in Michigan. Results indicate that centers serve a diverse array of consumers at an average cost of about $8 daily per person. Funding levels, salaries, and services are quite heterogeneous among centers. Those with higher funding levels, greater involvement with other human service agencies, and higher overall CMH county budgets differed significantly in total services and activities provided than those centers with less of each of these resources. Daily attendance was predicted by other-agency involvement, participation of volunteer personnel, and negative neighborhood context.
Fidelity criteria are increasingly used in program monitoring and evaluation, but are difficult to derive for emerging models (i.e., those not based on theory or a research demonstration project). We describe steps used to develop and operationalize fidelity criteria for consumer-run (CR) mental health services: articulating and operationalizing criteria based on published literature, then revising and validating the criteria through expert judgments using a modified Delphi method. Respondents rated highest those structural and process components emphasizing the value of consumerism: consumer control, consumer choices and opportunities for decision-making, voluntary participation (and the absence of coercion), and respect for members by staff.
Breakthrough Club of Sedgwick County started New Beginnings School as a flexible alternative to existing community-based educational programs. The school offers remedial coursework, as well as GED and high school diploma curricula, with the goal of facilitating post-secondary education and employment opportunities. Postsecondary educational alternatives include online, video-format, and correspondence courses that complement traditional supported education programming. The various educational program components support mental health consumers pursuing their educational objectives.
Objectives: Cost-effective programs are needed to assist homeless persons with severe mental illness in their transition from shelters to community living. The authors investigated the cost-effectiveness of the critical time intervention program, a time-limited adaptation of intensive case management, which has been shown to significantly reduce recurrent homelessness among men with severe mental illness. Methods: Ninety-six study participants recruited from a psychiatric program in a men's public shelter from 1991 to 1993 were randomly assigned to the critical time intervention program or to usual services. Costs and housing outcomes for the two groups were examined over 18 months. Results: Over the study period, the critical time intervention group and the usual services group incurred mean costs of $52,374 and $51,649, respectively, for acute care services, outpatient services, housing and shelter services, criminal justice services, and transfer income. During the same period, the critical time intervention group experienced significantly fewer homeless nights than the usual care group (32 nights versus 90 nights). For each willingness-to-pay value - the additional price society is willing to spend for an additional nonhomeless night - greater than $152, the critical time intervention group exhibited a significantly greater net housing stability benefit, indieating cost-effectiveness, compared with usual care. Conclusions: Although difficult to conduct, studies of the cost-effectiveness of community mental health programs can yield rich information for policy makers and program planners. The critical time intervention program is not only an effective method to reduce recurrent homelessness among persons with severe mental illness but also represents a cost-effective alternative to the status quo.
Supported Education (SEd) is emerging as an evidence-based practice (EBP) effective at helping individuals with psychiatric disabilities increase their educational achievement. Individual Placement and Support (IPS), a specialized form of supported employment (SE) for people with psychiatric disabilities, is an established EBP and has been suggested as an optimal vehicle through which SEd could be delivered. This study attempts to: (1) discover which elements of supported education services are perceived as important by IPS programs and (2) to determine what, if any, educational services are currently being provided within these programs. Respondents rated most highly providing concrete educational services and minimizing educational service barriers for participants. Although still rated highly, there was less importance placed on documenting outcomes or informing others about the educational services being provided by supported employment programs. Approximately 57% of programs were providing some form of educational service and support. The results from this survey provide information about how IPS and SEd are currently being delivered and highlights a need for further research about how SEd and IPS can be optimally delivered together.
Objective: While there has been much research on predictors of psychiatric hospitalizations there has been little research on the community resources, supports and processes used to divert a hospital episode. The purpose of this study is to address this gap by studying (1) the community resources available as an alternative to state psychiatric hospitalization; and (2) the practices exhibited when determining whether state hospitalization is necessary. Methods: A mixed methods design was developed. The purpose of the first arm was to assess what non-hospital resources were available to mental health centers. The second arm looked at the processes center staff goes through in determining hospitalization or community diversion. Results: Differences were noted between centers with high and those with low diversion rates. Centers that tended to use the state hospital less had more community diversion resources available, had an agency philosophy aimed at diversion, and used processes which included shared decision-making. Further, staff had more experience and established protocols to ensure follow-up services were in place. Conclusions: Agencies that fostered a philosophy and protocol focusing on community diversion, provided alternative resources for consumers in crisis, and had adequate monitoring and training increased diversion rates and avoided unnecessary hospitalizations.