The use of the social skills performance assessment (SSPA) among persons with serious mental illness: psychometric assessment and network analysis.

Background: Challenges in social functioning are a major obstacle in the recovery process of persons with serious mental illness. Majority of social functioning measures use self-report assessments.Aims: To validate the use of a performance based measure and examine a network analysis that explores the centrality of items. In addition, to explore the distinctiveness between the social skills performance assessment (SSPA), and a self-report measure of social quality of life (SQoL).Method: One hundred fifty eight participants were administrated with the SSPA and SQoL scale. Intra-class correlation, Pearson correlation and Network analysis were performed.Results: A differentiation between the SQoL items and the SSPA items appeared. The strongest nodes in the network were social appropriateness (7.413), focus (7.763) and clarity (7.438) from the SSPA measure. The nodes rated highest on the betweenness measure were affect from the SSPA and satisfaction with getting along with other people from the SQoL scale.Conclusions: Interventions should target the skills of focus, clarity and social appropriateness as they present the central items in the network.

The Special Challenges of Psychotherapy with Persons with Psychosis: Intersubjective Metacognitive Model of Agreement and Shared Meaning.

Agreement between client and therapist is an essential part of the therapeutic alliance. While there are general challenges to the creation of agreement and shared meaning in all psychotherapies, there are specific challenges while working with persons with psychosis. These challenges include the different narratives of the client and the therapist with regard to their roles and the description of the condition or problem, as well as possible stigmatic views and theoretical bias. Here we present a metacognitive intersubjective model as a framework for the understanding and resolutions of these challenges. Copyright © 2016 John Wiley & Sons, Ltd. KEY PRACTITIONER MESSAGE: Goal consensus, agreement and shared meaning are essential for a collaborative process and positive outcome in psychotherapy. Challenges to psychotherapy with persons with psychosis include the different narratives of the client and the therapist with regard to their roles and the description of the condition or problem, as well as possible stigmatic views and theoretical bias. In the intersubjective exchange, the concepts of metacognition and empathy can act as a framework for navigating between the possible challenges and the desired shared meaning and agreement.

Measuring the internalized stigma of parents of persons with a serious mental illness: the factor structure of the parents' internalized stigma of mental illness scale.

Research has revealed that approximately one third of persons with a serious mental illness (SMI) experience elevated internalized stigma, which is associated with a large number of negative outcomes. Family members of persons with SMI are also often subject to stigma, but the degree to which these experiences are internalized and lead to self-stigma has rarely been studied. The present study investigated the factor structure of a modification of the Internalized Stigma of Mental Illness (ISMI) scale by Ritsher, Otilingam, and Grajales (Psychiatry Res 121:31-49, 2003). A central assumption of this investigation was that the factor structure of the Parents' Internalized Stigma of Mental Illness (PISMI) scale would be similar to the factor structure of the ISMI scale. A total of 194 parents of persons with SMI completed the PISMI scale. The results revealed that the PISMI scale has high internal consistency and that it is made up of three distinctive factors: discrimination experience, social withdrawal and alienation, and stereotype endorsement. These factors are similar, but not identical, to the factors that underlie the ISMI scale. This study's findings also indicate that parents' prominent reaction to self-stigma is stereotype endorsement.

Recovery in Israel: a legislative recovery response to the needs-rights paradox.

This paper uses the framework of the applied social science needs/rights antinomy to describe the efforts of Israel's mental health system in transforming a hospital-based orientation to services for individuals with a severe mental illness, to a community-based recovery orientation. On the one hand, a rationale for the provision of services to individuals with a severe mental illness that stresses these individuals' needs can justify the allocation of society's limited resources by referring to an objectively determinable set of psychiatric needs. However, this rationale may establish an inherent asymmetry between the adequate help provider and deficient help user. On the other hand, a rationale for providing psychiatric rehabilitation services that stresses the fundamental symmetry between the help provider and the help user is empowering, thus consistent with the recovery approach. However, this rationale does not provide a mechanism for negotiating the vague boundary between mental health and mental illness. Israel's mental health system has operationalized a policy that emphasizes rights as well as needs by legislating for a comprehensive set of rehabilitation services that individuals meeting the eligibility criteria may receive. This paper discusses this approach's achievements, challenges and implications for future policy, research, and practice.

A narrative evaluation of a psychoeducation and a therapeutic alliance intervention for parents of persons with a severe mental illness.

Most attempts to study the impact of psychosocial interventions on parents of persons with severe mental illness (SMI) are quantitative. The purpose of the present study was to investigate the subjective experience of parents of persons with SMI who participated in either a psychoeducational intervention which emphasized providing information on the illness and support, or a therapeutic alliance focused intervention (TAFI) which emphasized the alliance between the group members and group leaders. Ninety-three parents, who participated in either one of these two interventions, were interviewed using the Narrative Evaluation of Intervention Interview. Results show that participants found both interventions to be beneficial with no statistical differences in the level of perceived change. Themes describing change in relating to illness were significantly more frequently mentioned by participants in the TAFI group, whereas significantly more participants in the family psychoeducation interventions reported that implementation and information provided contributed to positive change. Also participants in the TAFI reported significantly more often that group regulation contributed to change. As both interventions were perceived as contributing, the findings support the relationship orientation to psychosocial interventions, which stresses the quality of the social support and interpersonal interaction as the source of positive outcomes of intervention.

Family psychoeducation and therapeutic alliance focused interventions for parents of a daughter or son with a severe mental illness.

This study compared the effectiveness of a family psychoeducational intervention (FPEI) and a therapeutic alliance focused intervention (TAFI) for parents of daughters and sons with severe mental illness (SMI). A process-outcome model was used to compare the effectiveness of the two interventions and to evaluate how they achieved their outcomes. Extent of effectiveness was assessed in terms of the family burden (FB) of the parents and the quality of life (QoL) and psychiatric symptoms of the daughters and sons. This study did not uncover a difference in effectiveness between the two interventions. However, at post-treatment, the participants in both interventions reported statistically significant less FB and attributed more QoL and less psychiatric symptoms to their daughters and sons than at pre-treatment. In addition, these pre- and post-treatment differences were mediated by specific mediating variables. These results are discussed in terms of the great psychotherapy debate (Wampold, 2001) as to the relative effectiveness of technique oriented interventions as compared to context oriented interventions.

Insight into mental illness, self-stigma, and the family burden of parents of persons with a severe mental illness.

BACKGROUND: Parents of persons with severe mental illness (SMI) often experience burden due to the illness of their daughter or son. In the present study, the possibility that parents' self-stigma moderates the relationship between the parents' insight into a daughter's or son's illness and the parents' sense of burden was investigated. METHODS: Levels of insight into a daughter's or son's mental illness, parent self-stigma, and parent burden of 127 parents of persons with an SMI were assessed. Regression analysis was used to test the putative moderating role of parents' self-stigma. RESULTS: Self-stigma was found to mediate rather than moderate the relationship between insight and burden. Accordingly, parent insight into the mental illness of a daughter or son appears to increase parent burden because it increases parent self-stigma. CONCLUSIONS: The implications of these findings for practice, theory, and future research are discussed.

The relationship between consumer insight and provider-consumer agreement regarding consumer's quality of life.

This study examined the relationship between insight and mental health consumers and providers agreement regarding consumers rated quality of life (QoL). Seventy mental health consumers and their 23 care providers filled-out parallel questionnaires designed to measure consumer QoL. Consumers' insight was also assessed. For most QoL domains, agreement between consumers and providers was higher for persons with high insight. For the Psychological well being dimension a negative correlation was uncovered for persons with low insight indicating disagreement between consumer and provider. These findings are discussed within the context of the literature on insight and agreement between consumer and provider as related to the therapeutic alliance.

Insight into severe mental illness, hope, and quality of life of persons with schizophrenia and schizoaffective disorders.

Controversy exists as to the cognitive, emotional and behavioral consequences of lack of insight for persons with schizophrenia. This study tested a mediation model of the relations between insight into mental illness, hope, and the aspects of quality of life of persons with schizophrenia. According to this model, insight into mental illness may impact negatively on the quality of life of persons with schizophrenia by reducing these persons' hope. Sixty persons with schizophrenia or schizoaffective disorder completed questionnaires that assessed their insight, quality of life, and hope. The study's results show that for six of seven aspects of quality of life and for general awareness of illness, the above-hypothesized mediation model was confirmed. These results suggest that increasing the hope of persons with schizophrenia may directly and positively increase both their quality of life and the usefulness of their insight into their illness.

A one year follow-up of illness management and recovery: participants' accounts of its impact and uniqueness.

BACKGROUND: Illness Management and Recovery (IMR) is a standardized curriculum-based intervention to help people with serious mental illnesses acquire knowledge and skills to manage their illnesses effectively and achieve personal recovery goals. Recent evaluations of IMR have shown promising results with regard to feasibility and effectiveness. OBJECTIVES: The aim of the present study was to investigate and describe (1) whether participants perceived IMR as effective a year after completion, (2) if so, in what domains did they experience the IMR program to be beneficial, and, (3) in what ways did the IMR program differ from prior rehabilitation interventions they had experienced. METHOD: 36 people with serious mental illnesses completed the Narrative Evaluation of Intervention Interview (NEII), a year after completing IMR. Qualitative analysis of the interviews involved two judges independently identifying themes. Inter-rater reliability ranged from .63 to 1.00. RESULTS: Participants reported high levels of perceived helpfulness. Three domains of improvement attributed to IMR included cognition, coping, and social support. With regard to the uniqueness of the IMR intervention, five categories emerged: Learning new information, social support, coping and self management, program structure, and message of hope. CONCLUSIONS: The positive impact of IMR reported in previous studies lasts as long as a year. Domains of reported improvement partially overlap with outcomes reported in previous studies. IMR is perceived to differ in several ways from other psychiatric rehabilitation interventions, both in technique as well as in message.

Metacognitive and interpersonal interventions for persons with severe mental illness: theory and practice.

Communication and interpersonal deficits are major stumbling blocks that stand between persons with severe mental illness (SMI) and such recovery goals as quality of life (QoL) and community integration. Not only do these deficts have a direct and negative impact on the QoL and community integration of persons with SMI but they also may reduce these persons' ability to take advantage of major interventions in which communication and interpersonal relationships play a central role (i.e., psychotherapy, recovery programs, illness management and recovery). Recent theories of schizophrenia and other SMI attribute these communication and interpersonal limitations of persons with SMI to impairments of metacognition (i.e., empathy, theory of mind [ToM], mind reading). Within a dialogical framework of metacognition that differentiates between empathy and ToM, this paper reviews two interventions for persons with SMI, Metacognitive Training (MCT) and Social Cognition and Integration Training (SCIT), that were recently developed to improve communication and interpersonal skills of persons with schizophrenia. These interventions are based on the above described theories of schizophrenia and SMI. Although preliminary research has produced favorable results for these interventions, additional investigations using more critical research designs are required to establish their efficacy. Furthermore, this paper suggests that adding dialogical elements to these interventions might improve their effectiveness.

Assessing psychiatric rehabilitation service (PRS) outcomes in Israel: conceptual, professional and social issues.

Since the implementation of the legislation in Israel concerning rehabilitation of people with psychiatric disabilities in the community in 2001, an increasing number of individuals, currently estimated at nearly 15,000, have been receiving the psychiatric rehabilitation "basket of services." A systematic investigation of the extent to which these services have had a positive impact on the intended outcome is required, to evaluate the effectiveness of the newly developed psychiatric rehabilitation basket of services. This evaluation has become a priority item on the mental health agenda in Israel. This opinion paper, based on a conceptual analysis and selective review of the relevant literature, discusses concepts and principles that seem important for the development of strategies to constructively assess the outcome of psychiatric rehabilitation services (PRS) in Israel. More specifically, several fundamental issues related to outcome monitoring are reviewed, such as what outcome domains should be assessed, who should conduct the assessments and from whom should data be collected and with whom and how should it be shared. The complexity of these issues are reviewed and possible strategies to deal with them are discussed.

The psychometric properties of the Illness Management and Recovery scale: client and clinician versions.

The present study examined the psychometric properties of the clinician and client versions of the Illness Management and Recovery (IMR) scale. Using a 5-point behaviorally anchored response format, these scales were designed to tap the critical illness management and recovery domains targeted by the IMR program. This program is a curriculum-based approach to helping persons with a serious mental illness (SMI) acquire the knowledge and skills they need to manage their illness effectively and to achieve personal recovery goals. Two hundred and ten persons with a diagnosis of a SMI and their 13 clinicians filled-out the client and clinician versions of the IMR questionnaire. The clients also responded to measures of coping efficacy and social support. While indicating limitations of the IMR scales and pointing to how they could be improved, this study provided some support for the construct and concurrent validity of the client and clinician versions of the IMR questionnaire. Moderate reliabilities were uncovered for these parallel versions of the questionnaire. Client responses to the client IMR scale and clinician responses to the clinician IMR scale were shown to be characterized by similar major components of the IMR intervention.

Call it a monster for lack of anything else: narrative insight in psychosis.

Individuals diagnosed with schizophrenia often appear to be unaware of having an illness or actively reject their diagnostic label. It is unclear, however, how this lack of awareness relates to important outcomes. Broadening the definition of awareness to include "narrative insight" may clarify this issue. The objective of this study was to identify profiles of narrative insight and test how these relate to standardized measure of insight. Sixty-five individuals with schizophrenia spectrum disorders participated in an assessment that included the Scale of Unawareness of Mental Disorder (SUMD) and an in-depth semi-structured interview. Qualitative analysis revealed 5 central themes related to insight on the basis of which each interview was then rated. Cluster analysis of these ratings resulted in 4 profiles of narrative insight: (1) accepts illness/rejects label, (2) rejects illness/searches for a name (3) passive insight of illness and label, and (4) integrative insight. The SUMD differentiated between individuals assigned to profile 2 who showed low insight to their illness and those assigned to the other profiles of narrative insight, but could not differentiate between them. Results support the claim that illness narratives are multifaceted and that traditional measures of insight may not be sensitive to different ways in which people understand their illness.

A randomized controlled trial of the effectiveness of the illness management and recovery program.

OBJECTIVE: This study evaluated the effectiveness of the Illness Management and Recovery program implemented in a group format. METHODS: A total of 210 persons with a severe mental illness receiving treatment at rehabilitation centers in the community in Israel were randomly assigned to either the Illness Management and Recovery program or treatment as usual. The Illness Management and Recovery Scale (client and clinician versions) and measures of coping and social support were administered to participants before and after the intervention. RESULTS: Participants in the Illness Management and Recovery program showed significant improvement in knowledge about their illness and progress toward their personal goals compared with those receiving treatment as usual. Clinician ratings also indicated significant improvement in overall outcome for clients in the Illness Management and Recovery program compared with those who received treatment as usual. Significant improvement in coping was found in both groups, and no change in social support was found for either group. CONCLUSIONS: The Illness Management and Recovery program was effective in increasing clients' knowledge of their illness and helping them make progress toward personal goals.

Selecting and implementing evidence-based practices in psychiatric rehabilitation services in Israel: a worthy and feasible challenge.

Major recent conceptual and legal advancements in Israel have generated a profound shift in the services provided for people with severe mental illness. Perhaps the most influential development has been the passage of the act for the rehabilitation of persons with a psychiatric disability in the community in the year 2000. In this paper we argue that the psychiatric rehabilitation services defined by the recent legislation lack explicit standards or criteria for selection, and thus could benefit from incorporating interventions that evidence has shown to be effective in assisting clients to achieve desirable outcomes. We propose a practical five-step plan to facilitate the implementation of these evidence-based practices including creating demand, selecting the EBPs, preparing practitioners and agencies, monitoring and feedback, and ensuring sustainability. The importance of an ongoing dialogue between stakeholders to facilitate the integration of research evidence, clinical expertise and rehabilitation values to improve the quality of service is discussed.

Agreement between clients with schizophrenia and mental health workers on clients' social quality of life: The role of social cognition and symptoms.

OBJECTIVE: Studies have showed that therapists and mental health workers of persons with schizophrenia tend to estimate their patients' social quality of life (SQoL) as poorer than the clients' own estimation. This study explores the hypothesis that this discrepancy is related to clients' social cognition and symptomatology. DESIGN: Cross-sectional assessment of both clients and their mental health workers. METHODS: Ninety persons with schizophrenia and 12 persons who were formal care providers participated in the study. All responded to a parallel version (client and clinician) of social quality-of-life scales. Clients' emotion identification, theory of mind and symptoms were also assessed. RESULTS: Low social cognitive abilities of persons with schizophrenia, as well as negative symptomatology and having children, may be related to the negative bias of mental health workers, with regard to their client's SQoL. CONCLUSIONS: While more severe levels of negative symptoms and more deficits of social cognition were related to reduced levels of agreement, paradoxically, a relatively normative family life that includes parenting was also related to lower levels of agreement. PRACTITIONER POINTS: Attention should be given to low agreement between clients with schizophrenia and clinicians with regard to the client's quality of life, as it is central to alliance and outcome. Clinicians tend to estimate clients' social quality of life as poorer than the clients' own estimation when those clients have low social cognition, high negative symptomatology and children. There is a need to identify additional factors that contribute to agreement and alliance in therapy. Longitudinal assessment during therapy can trace the process of construction of agreement.

Neuro-cognition and social cognition elements of social functioning and social quality of life.

Previous studies have shown that deficits in social cognition mediate the association between neuro-cognition and functional outcome. Based on these findings, the current study presents an examination of the mediating role of social cognition and includes two different outcomes: social functioning assessed by objective observer and social quality of life assessed by subjective self-report. Instruments measuring different aspects of social cognition, cognitive ability, social functioning and social quality of life were administered to 131 participants who had a diagnosis of a serious mental illness. Results showed that emotion recognition and attributional bias were significant mediators such that cognitive assessment was positively related to both, which in turn, were negatively related to SQoL. While one interpretation of the data suggests that deficits in emotion recognition may serve as a possible defense mechanism, future studies should re-assess this idea.

Metacognitive and social cognition approaches to understanding the impact of schizophrenia on social quality of life.

While some studies view metacognition and social cognition as representing the same phenomenon, others suggest that they represent distinctive sets of abilities that are related to different outcomes. The current study used a cross-sectional design that includes samples of persons with schizophrenia (N=39) and healthy individuals (N=60) to further explore the distinction between social cognition and metacognition and their associations with social quality of life. The Face Emotion Identification Task (FEIT), Faux-Pas Task, Indiana Psychiatric Illness Interview (IPII), Metacognition Assessment Scale - Abbreviated (MAS-A), and Social Quality of Life Scale were administrated to all participants. Correlations, t-tests and regressions were conducted. Results showed that persons with schizophrenia performed more poorly on all measures than healthy controls. Social cognition and metacognition measures were related for the combined total sample, but only a few associations were found among both sub-samples. A diagnosis of schizophrenia and metacognitive capacity, but not social cognition, predicted social quality of life. Self-reflectivity had a negative relationship to social quality of life while understanding of others' minds had a positive relation to social quality of life. The current study provides evidence that many with schizophrenia experience deficits in both social cognition and metacognition and that those deficits may be distinct and have different kinds of relationships with social quality of life. Clinical implications include the need to emphasize narrative aspects of psychotherapy in order to promote metacognition.