Characteristics of users of consumer-run drop-in centers versus clubhouses.

Clubhouses and consumer-run drop-in centers (CRDIs) are two of the most widely implemented models of consumer-centered services for persons with serious mental illness. Differences in structure and goals suggest that they may be useful to different types of consumers. Information on what types of consumers use which programs would be useful in service planning. This study analyzes data from the authors' NIMH-funded research on 31 geographically matched pairs of clubhouses and CRDIs involving more than 1,800 consumers to address the following question: are there significant differences in the characteristics and outcomes of members of clubhouses versus CRDIs? Results from multilevel analyses indicated that clubhouse members were more likely to be female, to receive SSI/SSDI, to report having a diagnosis of schizophrenia, and to live in dependent care; and they reported both a greater number of lifetime hospitalizations and current receipt of higher intensity traditional MH services. Controlling for differences in demographic characteristics, psychiatric history, and mental health service receipt, clubhouse members also reported higher quality of life and were more likely to report being in recovery. CRDI consumers were more likely to have substance abuse histories. Possible reasons for the differences are discussed. The results suggest that CRDIs are a viable alternative to more traditional mental health services for individuals who might not otherwise receive mental health services.

Using planned adaptation to implement evidence-based programs with new populations.

The Interactive Systems Framework (ISF) for Dissemination and Implementation (Wandersman et al. 2008) elaborates the functions and structures that move evidence-based programs (EBPs) from research to practice. Inherent in that process is the tension between implementing programs with fidelity and the need to tailor programs to fit the target population. We propose Planned Adaptation as one approach to resolve this tension, with the goal of guiding practitioners in adapting EBPs so that they maintain core components of program theory while taking into account the needs of particular populations. Planned Adaptation is a form of capacity building within the Prevention Support System that provides a framework to guide practitioners in adapting programs while encouraging researchers to provide information relevant to adaptation as a critical aspect of dissemination research, with the goal of promoting wider dissemination and better implementation of EBPs. We illustrate Planned Adaptation using the JOBS Program (Caplan et al. 1989), which was developed for recently laid-off, working- and middle-class workers and subsequently implemented with welfare recipients.

The influence of gender, patient volume and time on clinical diagnostic decision making in psychiatric emergency services.

OBJECTIVE: We investigated the effects of limited time and high patient pressures on the role of gender and other nonpsychiatric factors in diagnostic decision making in psychiatric emergency services (PES). METHODS: We reviewed the records of 1236 adult psychiatric patients treated by 75 clinicians (e.g., psychiatrists, social workers, nurses and psychologists) in an urban university and community PES in early 2000. Patient records were sampled according to each clinician's level of busyness and load, controlling for the average number of patients typically seen and the actual volume of patients seen by the particular clinician during that shift. RESULTS: Multinomial logistic regression analyses reveal that clinicians are more likely to make a bipolar diagnosis when under low patient load [odds ratio (OR)=1.738, 95% confidence interval (CI)=1.186-2.546, P=.005] or when they have more time (OR=1.111, 95% CI=1.017-1.212, P<.019) and particularly when the patient is female (OR=0.286, 95% CI=0.1054-0.7785, P=.014). When clinicians are under high patient load, female patients are much more likely to receive a depressive disorder diagnosis (e.g., major depressive disorder and dysthymia) (OR=3.491, 95% CI=1.285-9.490, P=.014). CONCLUSIONS: The results highlight the potential difficulty of clinicians to differentiate bipolar disorder from other mental disorders when evaluating female patients, especially under high patient load, when social stereotypes may be more influential. The results have important implications for the use of antidepressant medications with female patients.

Relevance of spirituality for people with mental illness attending consumer-centered services.

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.

The clubhouse as an empowering setting.

Attention to psychosocial rehabilitation (PSR) practice has expanded in recent years. However, social work research studies on PSR are not numerous. This study focuses on operational characteristics of clubhouses, a major PSR program model, and the organizational attributes (including resource levels) that predict the extent to which the clubhouse constitutes an empowering setting. The authors present data from a statewide sample of 30 clubhouses, annually serving nearly 4,000 consumers (adults with serious mental illnesses), based on interviews of clubhouse directors, on-site observations, and government information sources. Results indicate that users were predominantly male, white, and middle age; about one-third had a major functional disability. There were wide variations in member characteristics as well as in resource levels. In terms of empowerment, this sample of clubs averaged rather low levels of member involvement in governance and operations but seemed to provide members with opportunities and assistance in making their own decisions. The empowerment variables had different predictors, including client characteristics, urban-related characteristics, staffing, and resource levels. Implications for social work practice in PSR settings are discussed.

Psychosocial outcomes for adult children of parents with severe mental illnesses: demographic and clinical history predictors.

Children of parents with mental illness are at risk of psychiatric and behavioral problems. Few studies have investigated the psychosocial outcomes of these children in adulthood or the parental psychiatric history variables that predict resilience. From a sample of 379 mothers with serious mental illnesses, 157 women who had at least one adult child between the ages of 18 and 30 were interviewed. Mothers reported that about 80 percent of these adult children were working, in school, or in training. However, about one-third had not completed high school, and 54 percent were judged to have a major problem in psychological, drug or alcohol, or legal domains. Although nearly 40 percent were parents of minor children, only about 12 percent were in a committed relationship. Mothers' bipolar diagnosis was a significant predictor for number of adult child problems. The results indicate a need for more attention to the parenting status of adults with mental illnesses and to their parenting concerns and needs.

Campus mental health services: recommendations for change.

College officials indicate that the number of students with serious mental illnesses has risen significantly. Recent media attention surrounding several high profile suicides has opened discussion of mental illness on campus. The authors summarize literature on college students and mental illness, including barriers to service receipt. Recommendations to improve campus-based responses to serious mental illness are presented on the basis of well-accepted service principles.

Understanding the policy context for supporting students with psychiatric disabilities in higher education.

Interest in postsecondary education for persons with psychiatric disabilities is high among consumers and advocates. However, the existence of program supports for higher educational goals is very uneven across U.S. states. This study was designed to examine the policy context in which states and educational institutions address needs of individuals with psychiatric disabilities to attend and succeed in postsecondary education. In 10 selected states, telephone interviews were conducted with key informants in state agencies of mental health, vocational rehabilitation, and higher education, as well as representatives of state-level advocacy organizations. Additionally, a search of websites relevant to state policy was conducted. The findings identify factors that facilitate and inhibit the development of policy and programs supportive of students with psychiatric disabilities. Facilitating factors include a strong community college system, progressive philosophy of the state mental health agency, and interest of consumers and the advocacy community. Inhibiting factors include political and budgetary uncertainty, competing priorities in the mental health system, emphasis on a medical rather than rehabilitative model, regulations of the VR system, and lukewarm enthusiasm of the advocacy community. Implications for community mental health services are included, particularly related to further policy development in support of students with psychiatric disabilities.

Relationship between maternal clinical factors and mother-reported child problems.

Maternal depression has been associated with mothers' elevated reports of child problems. However, it is unclear the extent to which elevations in mother ratings reflect having a depression diagnosis, having any mental illness diagnosis, or having a diagnosis vs. symptom levels. As part of a NIMH-funded, longitudinal study of mothers with serious mental illness (N=379), we examined the relationship between mother-reported adolescent behavior problems (N=78) and maternal depression vs. other diagnoses, as well as the effects of depression diagnosis vs. symptom levels. Mothers were recruited from the public mental health system in an urban area, and are primarily African-American and low income. We found that maternal psychiatric symptoms made a unique and significant contribution to explaining the variance in mother-reported child problems, independent of controls (e.g., teacher reports and child demographics), while maternal diagnosis did not. Implications of findings are discussed.

Rationing psychosocial treatments in the United States.

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.

Psychological traits and behavioral coping of psychiatric consumers: the mediating role of self-esteem.

A positive coping style can be critical to successful rehabilitation of psychiatric consumers. Using structural equation modeling, this study examined the relationships among consumers' psychological characteristics, self-esteem, and behaviors, and the role of self-esteem in mediating the relationships between psychological characteristics and behavioral coping. The sample consisted of 393 psychiatric consumers recruited from 25 psychosocial rehabilitation services (PSR) agencies. Key findings were that affective (that is, negative and positive affect) and cognitive (that is, beliefs in devaluation-discrimination) traits influence self-esteem and behavioral coping, and significant effects of affective and cognitive traits on behavioral coping are mediated by self-esteem. The findings suggest that interventions targeting self-esteem could be effective in modifying the behavioral coping of consumers served in PSR agencies. Implications for social work practice are discussed in relation to attitude change theories.

Timing of mental illness onset and motherhood.

The timing of mental illness onset in relationship to birth of children was explored as a possible indicator of the extent to which mothers experienced difficulties in parenting and functioning. Analyses employed data from a longitudinal study of urban-based, primarily minority mothers with mental illness (N = 379) who had parenting responsibility for their minor children. We found that women who were parents first and experienced mental illness onset after the birth of all their children showed the most positive trajectories over the study course. Mothers whose mental illness onset occurred before the birth of any of their children also showed improvements in functioning and symptomatology over time. In contrast, mothers whose mental illness onset had occurred in temporal proximity to the birth of a child showed little improvement. They also were younger, on average, at first birth, and had the largest number of children. Thus, timing of mental illness onset and childbirth may be predictive of longer-term maternal functioning and therefore may be useful in clinical assessment and treatment.

Consumer-run drop-in centers: program operations and costs.

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 dollar 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.

What affects self-esteem of persons with psychiatric disabilities: the role of causal attributions of mental illnesses.

This study addresses the factors which affect the self-esteem of persons with psychiatric disabilities, with a specific focus on the role of causal attributions of mental illnesses. It is based on data collected from 461 persons with psychiatric disabilities (consumers) served through psychiatric rehabilitation agencies. The results of regression analyses revealed that household income, diagnosis, psychiatric symptoms, service satisfaction, perceived stigma, and perceptions of social roles were all related to self-esteem. Consumers' causal attributions did not have direct effects on self-esteem, but the effects of causal attributions on self-esteem were moderated by psychiatric symptoms and by perceptions of social roles, suggesting that self-esteem enhancement strategies should be tailored to consumers' psychiatric and cognitive characteristics.

Higher education and psychiatric disabilities: national survey of campus disability services.

Students with psychiatric disabilities are an increasing presence on college and university campuses. However, there is little factual information about the services available to these students in campus disability services offices or the extent to which they use these services. This article reports the results of a survey of disability services offices at colleges and universities in 10 states. Data from 275 schools revealed the number of students with psychiatric disabilities seeking assistance from disability services offices, characteristics of these offices, and the types of services they provide. Survey data also identified barriers to full participation of these students in academic settings. Implications of the study are discussed to inform policy and postsecondary institutional practices with the goal of better serving psychiatrically disabled students to maximize their talents and potential.

Supported education for adults with psychiatric disabilities: an innovation for social work and psychosocial rehabilitation practice.

With medications that improve cognition and advances in knowledge of successful rehabilitative approaches, adults with psychiatric disabilities are increasingly able to pursue desired personal and career goals in their communities. This article focuses on supported education (SEd)-one of the newest psychosocial rehabilitation (PSR) models for adults with mental illness. The mission, principles, and service components of SEd are presented, reflecting its basis in PSR practice. Evidence of the effectiveness of supported education, based on research and evaluation studies, is provided. The authors conclude with a discussion of why PSR and SEd are important to social work and how social workers can effectively use this evidence-based practice to maximize opportunities for consumers with a mental illness.

Children of mothers diagnosed with serious mental illness: patterns and predictors of service use.

Children who have a parent diagnosed with a mental illness are at risk of psychiatric and behavioral problems; yet, these children do not necessarily receive needed services. Research has investigated correlates of child mental health service use, but not for these high-risk children. This study is part of an NIMH-funded, longitudinal investigation and describes child problems, service use, and predictors of service use for 506 children of 252 mothers diagnosed with serious mental illness. Mothers are primarily poor, minority women from urban areas. A multilevel-model approach is used to examine service use for multiple siblings in a family. More than one third of children had received services (from school or mental health agencies) in their lifetimes. Service use was predicted by child demographic characteristics (being male, non-African American, and older), social context variables (more negative life events, less financial satisfaction, and more parenting dissatisfaction), and maternal psychiatric variables (positively by high levels of case management receipt and affective diagnoses, negatively by maternal substance abuse history). In a subsample of "target children," mothers' rating of child behavior problems additionally predicted service use. Implications of results for research and intervention are discussed.

Critical ingredients of consumer run services: results of a national survey.

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.