Community Protection versus Individual Healing: Two Traditions in Community Mental Health.

This article identifies two major traditions that drive the mandate for a community mental health care system-community protection and individual healing. It discusses the historical antecedents of these two traditions and how these traditions relate to different visions of what the "common good" means. It then discusses how they both operate in the current US-based system, creating inherent conflicts and tensions, and gives specific examples from the personal and professional experiences of the authors. The article proposes ways to reduce the tension and discusses what sacrifices and compromises this resolution would entail for the US community mental health system. Copyright © 2017 John Wiley & Sons, Ltd.

Recovery from schizophrenia: with views of psychiatrists, psychologists, and others diagnosed with this disorder.

As the concept of schizophrenia began to develop over a century ago, it was accompanied by little hope of recovery. As the second half of the 20th century began, new treatments and changing social conditions resulted in most long-term patients being discharged into the community. Many of these expatients showed more improvement than had been expected. Treatment approaches evolved to help these persons live better lives in the community. In the recent past, psychosocial and psychiatric rehabilitation approaches to treatment have increasingly incorporated perspectives of persons in recovery. These perspectives are explored with emphasis on how they have helped drive federal government and other perspectives on recovery. Particular attention is given to the varying views of psychiatrists, psychologists, and other highly trained persons who have themselves been diagnosed and treated for schizophrenia.

Multimetallic arrays: bi-, tri-, tetra-, and hexametallic complexes based on gold(I) and gold(III) and the surface functionalization of gold nanoparticles with transition metals.

Reaction of [AuCl(PPh(3))] with the zwitterion S(2)CNC(4)H(8)NH(2) yields [(Ph(3)P)Au(S(2)CNC(4)H(8)NH(2))]BF(4). Treatment of this species with NEt(3) and CS(2) followed by [AuCl(PPh(3))] leads to [{(Ph(3)P)Au}(2)(S(2)CNC(4)H(8)NCS(2))], which can also be obtained directly from [AuCl(PPh(3))] and KS(2)CNC(4)H(8)NCS(2)K. A heterobimetallic variant, [(dppm)(2)Ru(S(2)CNC(4)H(8)NCS(2))Au(PPh(3))](+), can be prepared by the sequential reaction of [(dppm)(2)Ru(S(2)CNC(4)H(8)NH(2))](2+) with NEt(3) and CS(2) followed by [AuCl(PPh(3))]. Reaction of the same ruthenium precursor with [(dppm)(AuCl)(2)] under similar conditions yields the trimetallic complex [(dppm)(2)Ru(S(2)CNC(4)H(8)NCS(2))Au(2)(dppm)](2+). Attempts to prepare the compound [(dppm)Au(2)(S(2)CNC(4)H(8)NH(2))](2+) from [(dppm)(AuCl)(2)] led to isolation of the known complex [{(dppm)Au(2)}(2)(S(2)CNC(4)H(8)NCS(2))](2+) via a symmetrization pathway. [{(dppf)Au(2)}(2)(S(2)CNC(4)H(8)NCS(2))](2+) was successfully prepared from [(dppf)(AuCl)(2)] and crystallographically characterized. In addition, a gold(III) trimetallic compound, [{(dppm)(2)Ru(S(2)CNC(4)H(8)NCS(2))}(2)Au](3+), and a tetrametallic gold(I) species, [{(dppm)(2)Ru(S(2)CNC(4)H(8)NCS(2))Au}(2)](2+), were also synthesized. This methodology was further exploited to attach the zwitterionic (dppm)(2)Ru(S(2)CNC(4)H(8)NCS(2)) unit to the surface of gold nanoparticles, which were generated in situ and found to be 3.4 (+/-0.3) and 14.4 (+/-2.5) nm in diameter depending on the method employed. Nanoparticles with a mixed surface topography were also explored.

Multimetallic assemblies using piperazine-based dithiocarbamate building blocks.

Treatment of cis-[RuCl2(dppm)2] (dppm = bis(diphenylphosphino)methane) with dithiocarbamates, NaS2CNR2 (R = Me, Et) and [H2NC5H10][S2CNC5H10], yields cations [Ru(S2CNR2)2(dppm)2](+) and [Ru(S2CNC5H10)2(dppm)2](+), respectively. The zwitterions S2CNC4H8NHR (R = Me, Et) react with the same metal complex in the presence of base to yield [Ru(S2CNC4H8NR)(dppm)2](+). Piperazine or 2,6-dimethylpiperazine reacts with carbon disulfide to give the zwitterionic dithiocarbamate salts H2NC4H6(R2-3,5)NCS2 (R = H; R = Me), which form the complexes [Ru(S2CNC4H6(R2-3,5)NH2)(dppm)2](2+) on reaction with cis-[RuCl2(dppm)2]. Sequential treatment of [Ru(S2CNC4H8NH2)(dppm)2](2+) with triethylamine and carbon disulfide forms the versatile metalla-dithiocarbamate complex [Ru(S2CNC4H8NCS2)(dppm)2] which reacts readily with cis-[RuCl2(dppm)2] to yield [{Ru(dppm)2}2(S2CNC4H8NCS2)]. Reaction of [Ru(S2CNC4H8NCS2)(dppm)2] with [Os(CH=CHC6H4Me-4)Cl(CO)(BTD)(PPh3)2] (BTD = 2,1,3-benzothiadiazole), [Pd(C6H4CH2NMe2)Cl]2, [PtCl2(PEt3)2], and [NiCl2(dppp)] (dppp = 1,3-bis(diphenylphosphino)propane) results in the heterobimetallic complexes [(dppm)2Ru(S2CNC4H8NCS2)ML(n))](m+) (ML(n) = Os(CH=CHC6H4Me-4)(CO)(PPh3)2](+), m = 1; ML(n) = Pd(C,N-C6H4CH2NMe2), m = 1; ML(n) = Pt(PEt3)2, m = 2; ML(n) = Ni(dppp), m = 2). Reaction of [NiCl2(dppp)] with H2NC4H8NCS2 yields the structurally characterized compound, [Ni(S2CNC4H8NH2)(dppp)](2+), which reacts with base, CS2, and cis-[RuCl2(dppm)2] to provide an alternative route to [(dppm)2Ru(S2CNC4H8NCS2)Ni(dppp)](+). A further metalla-dithiocarbamate based on cobalt, [CpCo(S2CNC4H8NH2)(PPh3)](2+), is formed by treatment of CpCoI2(CO) with S2CNC4H8NH2 followed by PPh3. Further reaction with NEt3, CS2, and cis-[RuCl2(dppm)2] yields [(Ph3P)CpCo(S2CNC4H8NCS2)Ru(dppm)2](2+). Heterotrimetallic species of the form [{(dppm)2Ru(S2CNC4H8NCS2)}2M](2+) result from the reaction of [Ru(S2CNC4H8NCS2)(dppm)2] and M(OAc)2 (where M = Ni, Cu, Zn). Reaction of [Ru(S2CNC4H8NCS2)(dppm)2] with Co(acac)3 and LaCl3 results in the formation of the compounds [{(dppm)2Ru(S2CNC4H8NCS2)}3Co](3+) and [{(dppm)2Ru(S2CNC4H8NCS2)}3La](3+), respectively. The electrochemical behavior of selected examples is also reported.

Use of a consumer-led intervention to improve provider competencies.

OBJECTIVE: Client-centered care is a major aim of health care. In mental health, new client-centered treatment approaches that emphasize recovery, rehabilitation, and empowerment can improve outcomes for people with severe and persistent mental illness. However, these approaches are not widely used, in part because many clinicians lack the necessary competencies. The objective of this study was to evaluate the effectiveness of an innovative, consumer-led intervention, Staff Supporting Skills for Self-Help, which was designed to improve provider quality, empower mental health consumers, and promote mutual support. METHODS: The study was conducted at five large community mental health provider organizations in two western states. One organization in each state received the intervention. The intervention included education, clinician-client dialogues, ongoing technical assistance, and support of self-help. It focused on client-centered care, rehabilitation, and recovery. A one-year controlled trial evaluated the effect of the intervention on clinicians' competencies, care processes, and the formation of mutual support groups. Outcomes were assessed by using competency assessment survey instruments and semistructured interviews with clinicians and managers. RESULTS: A total of 269 clinicians participated in the study: 151 in the intervention group and 118 in the control group. Compared with clinicians at the control organizations, clinicians at intervention organizations showed significantly greater improvement in education about care, rehabilitation methods, natural supports, holistic approaches, teamwork, overall competency, and recovery orientation. CONCLUSIONS: A feasible, consumer-led intervention improves provider competencies in domains that are necessary for the provision of high-quality care.

Adherence to medication regimens and participation in dual-focus self-help groups.

OBJECTIVE: The authors examined the associations between attendance at self-help meetings, adherence to psychiatric medication regimens, and mental health outcomes among members of a 12-step self-help organization specifically designed for persons with both chronic mental illness and a substance use disorder. METHODS: A sample of members of Double Trouble in Recovery (DTR) was interviewed at baseline and one year later. Correlates of adherence to psychiatric medication regimens at the follow-up interview were identified for 240 attendees who had received a prescription for a psychiatric medication. RESULTS: Consistent attendance at DTR meetings was associated with better adherence to medication regimens after baseline variables that were independently associated with adherence were controlled for. Three baseline variables were associated with adherence: living in supported housing, having fewer stressful life events, and having a lower severity of psychiatric symptoms. In addition, better adherence was associated with a lower severity of symptoms at one year and no psychiatric hospitalization during the follow-up period. CONCLUSIONS: Treatment programs and clinicians should encourage patients who have both mental illness and a substance use disorder to participate in dual-focus self-help groups that encourage the responsible use of effective psychiatric medication, particularly after discharge to community living. Clinicians also should be sensitive to stressful life events and discuss with patients how such events might affect their motivation or ability to continue taking medication.

Role of self-help processes in achieving abstinence among dually diagnosed persons.

The effectiveness of participation in dual-focus groups (i.e., focusing on both mental health and substance use) has not been studied empirically. The study examined whether three hypothesized active ingredients of self-help (helper-therapy, reciprocal-learning, and emotional-support processes) are associated with drug/alcohol abstinence outcomes for members of a 12-step dual-focus fellowship, Double Trouble in Recovery (DTR). The study was able to control for member attitudes and behaviors at baseline, which might be related to both self-help processes and outcomes, i.e., extent of participation in DTR and traditional 12-step groups, prior drug/alcohol use, severity of psychiatric symptoms, motivation for change, stressful life events, perceived coping, self-efficacy for recovery, and social support. Members of 24 DTR groups in New York City were recruited, interviewed, and reinterviewed after 1 year. Drug/alcohol abstinence in the past year increased from 54% at baseline to 72% at follow-up. Helper-therapy and reciprocal-learning activities were associated with better abstinence outcomes, independent of other attitudes and behaviors of the members. However, emotional support was not related to outcome. We conclude that specific elements of self-help participation contribute substantially to progress in recovery for members of dual-focus groups; facilitating such self-help processes should be encouraged by clinicians and senior fellowship members.

The effect of 12-step based fellowship participation on abstinence among dually diagnosed persons: a two-year longitudinal study.

A large percentage of individuals are dually-diagnosed with a psychiatric disorder and a substance use disorder. Such persons typically face more difficulties and have poorer outcomes than do single disorder substance users. Among noncomorbid substance users, treatment and participation in 12-Step groups have been shown to enhance the likelihood of abstinence from substance misuse. Specialized 12-Step based fellowships have recently emerged to address the recovery needs of dually-diagnosed persons. The present study is a longitudinal investigation of the effect of such 12-Step based groups on abstinence among dually-diagnosed persons. Participants were members of Double Trouble in Recovery (DTR) who were recruited at community-based meetings in New York City and reinterviewed twice at yearly intervals. Generalized estimating equation analysis indicated that, over the two-year study period, ongoing DTR attendance was significantly associated with a greater likelihood of abstinence after controlling for other pertinent variables, such as mental health symptoms. For clinicians, these findings underline the importance of fostering stable affiliation with specialized 12-Step based groups among their clients.

Perceived reasons for substance misuse among persons with a psychiatric disorder.

The etiology of substance use among persons with severe mental illness remains unclear. This study investigates stated reasons for substance use among persons in recovery from co-occurring disorders of serious mental illness and substance abuse and dependence. The desire to fit in with peers played a key role in the initiation of substance use; boredom, loneliness, temptations to use, and stress were cited most as relapse triggers. The authors discuss the need for dually diagnosed persons to develop sobriety-supporting peer networks to help them learn adaptive strategies to deal with the stress of recovery; further, treatment programs should instill hope for recovery and provide opportunities for meaningful activities and relationships.

A new measure of coping with symptoms for use with persons diagnosed with severe mental illness.

The purpose of the present investigation was to develop and field test a measure of coping with symptoms specifically designed for use with persons diagnosed with severe mental illness. Findings are reported on both the development of the Coping with Symptoms Checklist and the initial field trial (n = 91) conducted to examine reliability and validity. Reliability was assessed by computing coefficient alpha, and validity was assessed by examining convergent and discriminant correlations (n = 79 for many analyses). Findings suggest that the measure is a generally reliable and valid way of assessing how persons diagnosed with severe mental illness cope with their symptoms.

Exemplary rural mental health services delivery.

Southeast Mental Health Services, in rural Colorado, has successfully transitioned from a traditional model of maintenance and control to one focused on recovery and community integration. They moved from delivering day treatment, congregate living, assertive community treatment and no-choice therapy to providing individuals with choice of goals and the supports needed to achieve and maintain their goals. As a result, consumers are now living independently. Currently, 38 percent of those with serious and persistent mental illness are working, going to school or volunteering. The keys to this transition have been peer support networks, home healthcare aides, field case management and a crisis hostel with no threshold of symptoms for its use. Southeast Mental Health Services has achieved results and is a national example of the "transformation" called for in the President's New Freedom Commission on Mental Health report.

Bifunctional dithiocarbamates: a bridge between coordination chemistry and nanoscale materials.

A dithiocarbamate-based methodology is employed to prepare linked heteromultimetallic complexes and then further exploited in the surface functionalisation of gold nanoparticles.

Multimetallic arrays: symmetrical bi-, tri- and tetrametallic complexes based on the group 10 metals and the functionalisation of gold nanoparticles with nickel-phosphine surface units.

Homobimetallic complexes of nickel, palladium and platinum, [(L2M)2(S2CNC4H8NCS2)]2+, are formed on reaction of the piperazine bis(dithiocarbamate) linker, KS2CNC4H8NCS2K, with [MCl2L2] (M=Ni, L2=dppe, dppf; M=Pd, L2=dppf; M=Pt, L=PEt3, PMePh2, PPh3, L2=dppf). [{Pd(C,N-C6H4CH2NMe2)}2(S2CNC4H8NCS2)] can be obtained in the same way. On reaction of [MCl2L2] (M=Pd, Pt) with the zwitterion S2CNC4H8NH2, a symmetrisation process occurs to yield a mixture of the complexes [M(S2CNC4H8NH2)L2]2+ and [(L2M)2(S2CNC4H8NCS2)]2+. However, the monometallic complexes [L2Ni(S2CNC4H8NH2)]2+ (L2=dppe, dppf) and [(L2Ni)2(S2CNC4H8NCS2)]2+ can be prepared without ready symmetrisation. Starting from the previously reported [(dppm)Ru(S2CNC4H8NH2)]2+, the heterotrimetallic products [(dppm)Ru(S2CNC4H8NCS2)M(dppf)]2+ (M=Pd, Pt) can be prepared without symmetrisation occurring. The crystal structures of five complexes are reported. The metalla-dithiocarbamate complexes [L2Ni(S2CNC4H8NCS2)] (L2=dppe, dppf) were used to functionalise the surface of gold nanoparticles by the displacement of a citrate shell to yield NiAu and FeNiAu materials.

Effects of "dual focus" mutual aid on self-efficacy for recovery and quality of life.

Four million adults in the U.S. have co-occurring serious mental illness and a substance use disorder. Mutual aid can usefully complement treatment, but people with co-occurring disorders often encounter a lack of empathy and acceptance in traditional mutual aid groups. Double Trouble in Recovery (DTR) is a dual focus fellowship whose mission is to bring the benefits of mutual aid to persons with dual diagnoses. Three hundred and ten persons attending 24 DTR groups in New York City during 1998 were interviewed and followed-up for two years. A mediational model was specified and results across time were summarized with generalized estimating equations (GEE). Degree of DTR Affiliation (attendance and involvement) was significantly associated with Self-efficacy for Recovery and three quality of life measures: Leisure Time Activities, Feelings of Well-Being and Social Relationships. Self-efficacy fully mediated the effects of DTR Affiliation on Leisure Time and Feelings and partially mediated DTR's effect on Social Relationships. The association of DTR involvement with self-efficacy is consistent with the processes inherent in mutual aid, although the observational nature of these data preclude causal inference. To improve outcomes, clinicians should facilitate affiliation with dual focus groups among persons with dual diagnoses as part of a comprehensive treatment approach.

An instrument to assess competencies of providers treating severe mental illness.

One approach to improving the quality of care for severe mental illnesses (SMI) such as schizophrenia is through the improvement of provider competencies; the attitudes, knowledge, and skills needed to deliver high-quality care. This paper describes a new instrument designed to measure such a set of competencies. A total of 341 providers of services to clients with SMI at 38 clinics within 5 publicly financed treatment organizations in 2 western states were asked to complete a paper-and-pencil survey including the new Competency Assessment Instrument (CAI: 15 scales, each assessing a particular provider competency), and additional measures used to establish validity (Recovery Attitude Questionnaire--7, Client Optimism Scale). Seventy-nine percent (N = 269) responded at baseline, 83% (N = 282) responded at 2 weeks. Ninety-seven percent of baseline respondents completed the survey at 2 weeks. Most CAI scales have good internal consistency (Cronbach's alphas = .52-.93), test-retest reliability (scales ranged from .42 to .78), and validity, and should be useful in efforts to improve care.

Social support mediates the effects of dual-focus mutual aid groups on abstinence from substance use.

BACKGROUND: Specialized 12-step based groups have emerged to address the needs of persons recovering from both substance abuse and psychiatric illness. OBJECTIVE: This study investigates the role of social support in mediating the association between mutual aid participation and subsequent substance use for dually diagnosed persons. METHOD: A cohort of Double Trouble in Recovery (DTR) members in New York City were studied prospectively over a two-year period. FINDINGS: Longer DTR participation during the first year of the study was associated with lower substance use in the second year; that effect was partially explained by the maintenance of high level of social support. CONCLUSION: These findings speak of the enduring influence of 12-step attendance on reducing substance use, and underline the importance of both 12-step attendance and supportive networks for dually diagnosed persons.

DOUBLE TROUBLE IN RECOVERY: SELF-HELP FOR PEOPLE WITH DUAL DIAGNOSES.

Self-help is gaining increased acceptance among treatment professionals as the advent of managed care warrants the use of cost-effective modalities. Traditional "one disease-one recovery" self-help groups cannot serve adequately the needs of the dually diagnosed. This article discusses Double Trouble in Recovery (DTR), a 12-step self-help group designed to meet the special needs of those diagnosed with both a psychiatric disability and a chemical addiction, DTR differs from traditional self-help groups by offering people a safe forum to discuss their psychiatric disabilities, medication, and substance abuse. Preliminary data collected at four DTR sites in NYC indicate that DTR members have a long history of psychiatric disabilities and of substance abuse, and extensive experience with treatment programs in both areas. They are actively working on their recovery, as evidenced by their fairly intensive attendance at DTR. Recent substance use is limited, suggesting that participation in DTR (in conjunction with format treatment when needed) is having a positive effect. Most members require medication to control their psychiatric disabilities, and that alone may make attendance at "conventional" 12-step groups uncomfortable. Ratings of statements comparing DTR to other 12-step meetings suggest that DTR is a setting where members can feel comfortable and safe discussing their dual recovery needs.

Predictors of retention in dual-focus self-help groups.

Attendance at 12-step groups has been found useful in maintaining abstinence from substance use; many members disengage early, missing out on potential benefits. New 12-step based groups have emerged to address the recovery needs of the many substance users with psychiatric comorbidity. Little is known about factors associated with retention in 12-step, especially in this population. This study sought to identify predictors of retention over a one-year period among members of a dual-focus 12-Step fellowship (N = 276). Using multivariate analysis, the following baseline characteristics were associated with greater retention one year later: older age, more lifetime arrests, abstinence in the pre-baseline year, more psychiatric symptoms in the pre-baseline year, not taking psychiatric medication, being more troubled by substance abuse than by mental health, and greater level of self-efficacy for recovery; residing in supported housing and being enrolled in outpatient treatment at follow-up were also significantly associated with better retention. Clinical implications to enhance retention in specialized 12-step groups are discussed.