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.

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.

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.

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.

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.

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.

Interest in and obstacles to pursuing work among unemployed dually diagnosed individuals.

Employment status is commonly used as a sign of stability in recovery and an outcome variable for substance abuse treatment and research. However, there has been little attention in the literature on the topic of work for the dually diagnosed (i.e., persons diagnosed with both substance use and mental health disorders). Data collected in 1999 are presented on expressed interest in and perceived barriers to pursuing work and on the utilization of vocational rehabilitation (voc-rehab) services among unemployed members of a dual recovery self-help fellowship (N= 130). While members generally expressed high interest in working, they also cited multiple obstacles to attaining and maintaining employment. A path model was specified and tested. Significant contributors to interest in working were substance use status and physical health rating. Consistent with our hypotheses, mental health symptoms and greater perceived obstacles (e.g., stigma, fear of failure, and insufficient skills) were significant contributors to perceived difficulty in pursuing work, whereas substance use, physical health, and recency of employment were not. Finally, those who perceived less difficulty in pursuing work were more likely to utilize voc-rehab services, and men were more likely than women to use these facilities; interest in work was not significantly associated with utilizing voc-rehab services. The roles of mental health disorders and substance use in relation to pursuit of employment are discussed, as well as that of perceived obstacles such as stigma. The paper addresses the setting of realistic vocational goals and possible strategies to mitigate barriers to increased employment of dually diagnosed individuals.

Participation in 12-Step-Based Fellowships Among Dually-Diagnosed Persons.

Twelve-step groups (12SG), a useful recovery resource, are underutilized by dually-diagnosed persons. There has been little empirical research in this area. This study followed members of a dual-focus 12-step-based fellowship (N = 277) over one year to gain a greater understanding of participation in both specialized dual focus and traditional 12SG among dually-diagnosed persons, including reasons for attending, perceived benefits of and obstacles to affiliation, and predictors of affiliation. Findings indicate that dually-diagnosed persons do engage in both types of fellowships; patterns of engagement differed across fellowships, suggesting different comfort levels. Both types of fellowships were used to deal with addiction. Greater difficulty with substance use at baseline was associated with greater likelihood of attending 12SG at follow-up; the reverse was true for self-reported substance use at baseline. Findings are discussed in light of existing literature and clinical implications are suggested.

Mediators of effectiveness in dual-focus self-help groups.

Although research on the effectiveness of 12-step group participation has been increasing, there has been little examination of the processes by which such participation leads to positive outcomes. Two kinds of factors have been proposed as mediating between 12-step group affiliation and outcomes for members, common process factors that have been identified in a range of behavioral treatments and factors that are relatively unique to the 12-step model. The study tested the hypotheses that two common process factors (internal locus of control and sociability) and two unique factors (spirituality and installation of hope) mediate the effects of 12-step group affiliation on drug/alcohol abstinence and health promoting behavior. The study respondents were members of a dual focus 12-step-based fellowship, Double Trouble in Recovery (DTR), designed to address issues of both substance use and mental health. Members of 24 DTR groups in New York City were recruited and followed-up for 1 year. The degree of 12-step group affiliation during the study period was associated with more positive outcomes at follow-up. Internal locus of control and sociability mediated the effects of 12-step group affiliation on both outcomes, whereas spirituality and hope acted as mediators only for health promoting behavior. Understanding that the therapeutic factors inherent in 12-step are not mysterious, but appear to capitalize on well-documented social learning principles, may increase the acceptance of 12-step programs among addiction and mental health professionals.