Examination of Adaptations to the Evidence Based Supported Employment Model: Individual Placement and Support.

Individual Placement and Support (IPS) is a long-standing and innovative employment service for individuals with mental illness with dozens of clinical trials demonstrating effectiveness. Little is known, however, about intentional adaptations to IPS, especially those outside of the context of research studies. Using an implementation science framework, we conducted an exploratory study to better understand the characteristics of stakeholder-reported adaptions to IPS, the impetus for their development, and perceived impacts. We conducted qualitative interviews to analyze and describe these adaptations. Numerous adaptations of IPS were found that address the needs of new and underserved populations both within and outside of the mental health field. Programs reported adapting IPS because of the dearth of other evidence-based employment services, to serve diverse populations in need, and based on financial incentives. Benefits of adaptations were weighed against impacts on fidelity. As evidence-based practices (EBPs) are adapted, developers of EBPs should determine how fidelity of a program or service can be assessed or preserved in light of adaptations. This is critical with the increase in different service delivery methods, new populations, new service recipient needs, and new settings in need of EBPs.

Fetal cerebrovascular impedance is reduced in left congenital diaphragmatic hernia.

OBJECTIVES: Congenital diaphragmatic hernia (CDH) can cause a significant mass effect in the fetal thorax, displacing the heart into the opposite hemithorax. In left-sided CDH (L-CDH), this is associated with smaller left-sided cardiac structures and reduced left-ventricular cardiac output (LVCO). The effect of these physiologic changes on cerebral blood flow is not well understood. We sought to describe the middle cerebral artery (MCA) pulsatility index (PI), a measure of cerebrovascular impedance, in fetuses with L-CDH and those with right-sided CDH (R-CDH) compared with unaffected fetuses, and the relationship between MCA-PI and LVCO. We hypothesized that MCA-PI would be lower in fetuses with L-CDH and similar in those with R-CDH compared to controls, and that MCA-PI would be correlated with LVCO. METHODS: We identified all fetuses with CDH evaluated at The University of California San Francisco, San Francisco, CA, USA from 2011 to 2018. Fetal echocardiograms and ultrasound scans were reviewed. Umbilical artery and MCA Doppler examinations were assessed to calculate pulsatility indices. Ventricular outputs were calculated using Doppler-derived stroke volume and fetal heart rate. Lung-to-head ratio (LHR), estimated fetal weight, biparietal diameter (BPD) and head circumference (HC) were obtained from fetal sonograms. Measurements in fetuses with CDH, according to the side of the defect, were compared with those in unaffected, gestational age-matched controls. A subset of CDH survivors had available data on neurodevelopmental outcome, as assessed using the Bayley Scales of Infant Development, 3rd edition. RESULTS: A total of 64 fetuses with CDH (L-CDH, n = 53; R-CDH, n = 11) comprised the study groups, with 27 unaffected fetuses serving as controls. Mean gestational age at evaluation was similar between the three groups. Compared to controls, fetuses with L-CDH had significantly lower LVCO expressed as a percentage of combined cardiac output (CCO) (32%; 95% CI, 29-35% vs 38%; 95% CI, 33-42%; P = 0.04) and lower MCA-PI Z-score (-1.3; 95% CI, -1.7 to -1.0 vs 0.08; 95% CI, -0.5 to 0.6; P < 0.001), while they did not differ between the R-CDH group and controls. There was a strong positive association between LVCO as a percentage of CCO and MCA-PI Z-score in the overall cohort of CDH and control fetuses (P = 0.01). BPD and HC were similar between the three groups. At neurodevelopmental follow-up, mean cognitive, motor and language scores in the CDH group were within 1 SD of those in the general population. CONCLUSION: MCA-PI values are significantly lower in fetuses with L-CDH as compared to controls, and lower LVCO was correlated with lower MCA vascular impedance. The neurodevelopmental effect of changes in MCA-PI in response to decreased LVCO is unknown, although, on average, CDH survivors had neurodevelopmental scores in the normal range. This may reflect a fetal compensatory mechanism in response to diminished antegrade cerebral blood flow. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.

COVID-19: relationship between atmospheric temperature and daily new cases growth rate.

Purpose: The novel coronavirus (severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2)) first appeared in Wuhan, China, in December 2019, and rapidly spread across the globe. Since most respiratory viruses are known to show a seasonal pattern of infection, it has been hypothesised that SARS-CoV-2 may be seasonally dependent as well. The present study looks at a possible effect of atmospheric temperature, which is one of the suspected factors influencing seasonality, on the evolution of the pandemic. Basic procedures: Since confirming a seasonal pattern would take several more months of observation, we conducted an innovative day-to-day micro-correlation analysis of nine outbreak locations, across four continents and both hemispheres, in order to examine a possible relationship between atmospheric temperature (used as a proxy for seasonality) and outbreak progression. Main findings: There was a negative correlation between atmospheric temperature variations and daily new cases growth rates, in all nine outbreaks, with a median lag of 10 days. Principal conclusions: The results presented here suggest that high temperatures might dampen SARS-CoV-2 propagation, while lower temperatures might increase its transmission. Our hypothesis is that this could support a potential effect of atmospheric temperature on coronavirus disease progression, and potentially a seasonal pattern for this virus, with a peak in the cold season and rarer occurrences in the summer. This could guide government policy in both the Northern and Southern hemispheres for the months to come.

Psychologists' perspectives on supported decision making in Ireland.

BACKGROUND: A new legal capacity act was introduced in Ireland in 2015. This study aimed to identify and critically examine key issues in the area of decision-making capacity from the perspective of psychologists working with adults with an intellectual disability. METHODS: A qualitative exploratory approach was employed, and the study was positioned in a social constructionist framework. Purposive and snowballing sampling methods were used to recruit 15 clinical psychologists working with adults with an intellectual disability. Data were collected with the use of individual semistructured interviews. Interview transcripts were analysed using a model of thematic analysis. RESULTS: Six themes were identified: (1) a presumption of capacity but a culture of incapacity, (2) supporting decision making as a process, (3) authenticity of decision making, (4) need for support and training, (5) contributions of psychology and (6) the way forward. CONCLUSIONS: Participants described that people with intellectual disabilities were often excluded from decision-making processes. They welcomed the functional approach to decision making, considered substituted decision making to be necessary within a support framework and described supporting decision making as a process. Systemic, resource and attitudinal challenges were identified.

Defining Employment Specialist Competencies: Results of a Participatory Research Study.

The preponderance of research conducted on supported employment has focused on the structure of interventions with little empirical investigation into the contribution of employment specialists to work outcomes. Using a participatory approach, we identified competencies essential to the role of the employment specialists, operationalized and refined those competencies using the perspectives of experts, service recipients, and employment specialists themselves. We conducted an online survey with 34 candidate items and n = 142 respondents. Results suggested good psychometric properties, stability and coherence of the Vocational Practices and Relationship Scale. A total of n = 23 final items tapping the working alliance coalesced into a strong factor, as did strategies for promoting vocational recovery, suggesting that the scale warrants wide-scale testing for predictive validity. We consider these constructs and competencies to be a potential blueprint for training employment specialists, not only in technical skills and strategies, but also to increase the hope for vocational recovery among those they serve.

Stakeholder-driven approach to developing a peer-mentoring intervention for young adults with intellectual/developmental disabilities and co-occurring mental health conditions.

BACKGROUND: Young adults with intellectual/developmental disabilities and co-occurring mental health conditions (IDD-MH) experience significant mental health disparities. Barriers to services include transportation and stigma associated with services. Peer mentoring (PM) may be one solution to these barriers. METHODS: We conducted exploratory research to develop a PM intervention for young adults with IDD-MH by partnering with 3 young adults with IDD-MH and a seven-member advisory board. In addition, we conducted focus groups with mental health clinicians (n = 10), peer providers (n = 9), and transition specialists (n = 20) to identify the desired PM outcomes and features and content that may facilitate these outcomes. RESULTS: Prioritized outcome: identifying and utilizing leisure activities as coping strategies. PM features: mentors should use relationship- and outcome-driven actions to operationalize a mentee-centred approach. Features and content considerations: safety, mentor matching, degree of structure, mentor training and support, and collaboration with mentees' support teams. DISCUSSION: Findings are aligned with previous research on PM.

Socially Valued Roles, Self-Determination, and Community Participation among Individuals Living with Serious Mental Illnesses.

Decades after deinstitutionalization, individuals living with serious mental illnesses remain isolated, socially disengaged, and devalued members of communities. Burgeoning research and services need conceptual clarity to improve such social conditions. This qualitative inquiry used grounded theory and participatory approaches to conduct an in-depth exploration of community participation for individuals living with serious mental illnesses based on key stakeholder perspectives (n = 45). Results revealed that community participation is a multifaceted construct with layers of meaning for individuals living with serious mental illnesses. Overarching themes are contextualized in Self-Determination Theory and presented with deidentified illustrations. Implications for services, research, and policy are discussed.

Predictors of Sustained Employment Among Individuals With Serious Mental Illness: Findings From a 5-Year Naturalistic Longitudinal Study.

Despite decades of research, understanding of the employment trajectories of individuals with serious mental illnesses remains elusive. We conducted a 5-year prospective, longitudinal study using a geographically broad sample of individuals who met established criteria for sustained competitive employment (N = 529). We collected data on an annual basis with a specifically designed survey instrument. Despite stable employment at study entry, more than half of the participants experienced work interruptions during the 5-year follow-up period. Predictors of sustained employment included the absence of a trauma diagnosis, Social Security disability income, psychiatric hospitalizations, and difficulties with daily functioning. The presence of a higher quality of life, workplace supports, and a flexible job were also predictive. Results dispel the myth that people with serious mental illnesses cannot be employed for prolonged periods. Interruptions in work trajectories, however, suggest that longer-term supports may increase individuals' capacity to maintain stable employment.

Immune responses in hibernating little brown myotis (Myotis lucifugus) with white-nose syndrome.

White-nose syndrome (WNS) is a fungal disease responsible for decimating many bat populations in North America. Pseudogymnoascus destructans (Pd), the psychrophilic fungus responsible for WNS, prospers in the winter habitat of many hibernating bat species. The immune response that Pd elicits in bats is not yet fully understood; antibodies are produced in response to infection by Pd, but they may not be protective and indeed may be harmful. To understand how bats respond to infection during hibernation, we studied the effect of Pd inoculation on the survival and gene expression of captive hibernating Myotis lucifugus with varying pre-hibernation antifungal antibody titres. We investigated gene expression through the transcription of selected cytokine genes (Il6, Il17a, Il1b, Il4 and Ifng) associated with inflammatory, Th1, Th2 and Th17 immune responses in wing tissue and lymph nodes. We found no difference in survival between bats with low and high anti-Pd titres, although anti-Pd antibody production during hibernation differed significantly between infected and uninfected bats. Transcription of Il6 and Il17a was higher in the lymph nodes of infected bats compared with uninfected bats. Increased transcription of these cytokines in the lymph node suggests that a pro-inflammatory immune response to WNS is not restricted to infected tissues and occurs during hibernation. The resulting Th17 response may be protective in euthermic bats, but because it may disrupt torpor, it could be detrimental during hibernation.

Standing up in multiple sclerosis (SUMS): protocol for a multi-centre randomised controlled trial evaluating the clinical and cost effectiveness of a home-based self-management standing frame programme in people with progressive multiple sclerosis.

BACKGROUND: Multiple sclerosis (MS) is an incurable, unpredictable but typically progressive neurological condition. It is the most common cause of neurological disability in young adults. Within 15 years of diagnosis, approximately 50 % of affected people are unable to walk unaided, and over time an estimated 25 % depend on a wheelchair. Typically, people with such limited mobility are excluded from clinical trials. Severely impaired people with MS spend much of their day sitting, often with limited ability to change position. In response, secondary complications can occur including: muscle wasting, pain, reduced skin integrity, spasms, limb stiffness, constipation, and associated psychosocial problems such as depression and lowered self-esteem. Effective self-management strategies, which can be implemented relatively easily and cheaply within people's homes, are needed to improve or maintain mobility and reduce sedentary behaviour. However this is challenging, particularly in the latter stages of disease. Regular supported standing using standing frames is one potential option. METHODS/DESIGN: SUMS is a pragmatic multi-centre randomised controlled trial evaluating use of Oswestry standing frames with blinded outcome assessment and full economic evaluation. Participants will be randomly allocated (1:1) to either a home-based, self-management standing programme (with advice and support) along with their usual care or to usual care alone. Those in the intervention group will be asked to stand for a minimum of 30 min three times weekly over 20 weeks. Each participant will be followed-up at 20 and 36 weeks post baseline. The primary clinical outcome is motor function, assessed using the Amended Motor Club Assessment. The primary economic endpoint is quality-adjusted life years. The secondary outcomes include measures of explanatory physical impairments, key clinical outcomes, and health-related quality of life. An embedded qualitative component will explore participant's and carer's experiences of the standing programme. DISCUSSION: This is the first large scale multi-centre trial to assess the clinical and cost effectiveness of a home based standing frame programme for people who are severely impaired by MS. If demonstrated to be effective and cost-effective, we will use this evidence to develop recommendations for a health service delivery model which could be implemented across the United Kingdom. TRIAL REGISTRATION: ISRCTN69614598 DATE OF REGISTRATION: 3.2.16 (retrospectively registered).

A Randomized Clinical Trial Investigating the Effect of a Healthcare Access Model for Individuals with Severe Psychiatric Disabilities.

We conducted a randomized trial to examine a model for integrating primary care into a community mental health setting. Two hundred individuals were recruited and randomly assigned to receive primary care delivered by a nurse practitioner (n = 94) or services-as-usual (n = 106), assessed on health and mental health outcomes, and followed for 12 months. Intent-to-Treat and exposure analyses were conducted and suggest that participants who engaged with the nurse practitioner experienced gains in perceptions of primary care quality. Health benefits accrued for individuals having receiving nurse practitioner services in a mental health setting to address primary care needs.

The role of inflammation-related genes in osteoarthritis.

In this review article we examine the role of inflammation-related genes in osteoarthritis (OA) from the perspective of genetics, epigenetics and gene expression. There have been great strides in such genomic analyses of OA in recent years thanks to the study of adequately powered patient cohorts, the detailed analysis of candidate genes, and the application of genome-wide approaches. These have led to some unexpected and therefore exciting discoveries, implicating pathways that would not necessarily have been predicted to have a role in this common arthritis. Inflammatory-related genes sit firmly in the candidate camp based on prior observations that the OA disease process can have an inflammatory component. What is clear from the genetic studies published to date is that there is no compelling evidence that DNA variation in inflammatory genes is an OA risk factor. This conclusion may of course change as ever more powerful association studies are conducted. There is, however, compelling evidence that epigenetic effects involving inflammatory genes are a component of OA and that alteration in the expression of these genes is also highly relevant to the disease process. We may in fact be close to demonstrating, at the genomic level, a clear separation of OA patients into those in whom inflammation is a key driver of the disease and those in whom it is not. This has obvious implications for the design of trials of novel OA interventions and may also guide the intelligent re-purposing of anti-inflammatory therapies.

Prostate cancer risk assessment tools in an unscreened population.

OBJECTIVE: To compare the prostate cancer prevention trial risk calculator (PCPT-RC) and European randomized study of screening for prostate cancer risk calculator (ERSPC-RC) in a unique unscreened population from the West of Ireland. PATIENTS AND METHODS: Data was prospectively recorded for all 556 consecutive men who underwent prostate biopsy at our institution as part of the Rapid Access Prostate Assessment Clinic program in Ireland. The estimated probabilities of detecting prostate cancer and high-grade disease were calculated using the PCPT and ERSPC risk calculators. For each calculator the discriminative ability, calibration and clinical utility was assessed. RESULTS: Prostate cancer was detected in 49% and high-grade prostate cancer in 34% of men. Receiver operating characteristic curve analysis demonstrated that the PCPT-RCs outperformed the ERSPC-RCs for the prediction of prostate cancer areas underneath the ROC curve (AUC 0.628 vs. 0.588, p = 0.0034) and for the prediction of high-grade prostate cancer (AUC 0.792 vs. 0.690, p = 0.0029). Both risk calculators generally over-predicted the risk of prostate cancer and high-grade disease across a wide range of predicted probabilities. Decision curve analysis suggested greater net benefit using the PCPT-RCs in this population. CONCLUSIONS: Multivariable nomograms can further aid patient counselling for early prostate cancer detection. In unscreened men from Western Ireland, the PCPT-RCs provided better discrimination for overall prostate cancer and high-grade disease compared to the ERSPC-RC. However, both tools overpredicted the risk of cancer detection on biopsy, and it is possible that a different set of predictive variables may be more useful in this population.

Penile cancer--Guideline adherence produces optimum results.

OBJECTIVE: To audit the management and outcome of penile cancer in a tertiary university teaching hospital, comparing our results to international best practice and published guidelines. METHODS: The Hospital Inpatient Enquiry database of the Mercy University Hospital was interrogated for penile cancer patients treated between 2001 and 2012. Data relating to presentation, local treatment, histology, lymph-node management, outcome and survival was recorded. Data were analysed using the Log Rank test, with significance defined as P ≤ 0.05. RESULTS: Twenty-five patients were identified with a median age of 61 years. The majority of cases at presentation were ≥ T2 (54%) and intermediate to high grade (76%). The median follow-up of patients was 3.75 years (range 9 months-10 years). Overall survival was 76% (n = 19), these patients are all disease free to date. Disease-specific survival was 85% at 10 years. Penile cancer related mortality was 8% (n = 2), 4 patients (16%) died of non-penile cancer related causes. Twenty-two patients (88%) had surgery and 3 patients (12%) had radiotherapy. Based on EAU guidelines inguinal lymph node dissection (ILND) was performed in 64% (n = 16) of cases with 44% (n = 7) of these patients requiring concurrent bilateral pelvic lymph node dissection. Fifty percent (n = 8) of ILNDs showed metastatic disease. Ten year disease-specific survival for node negative versus node positive disease is 100% versus 57%. Thirty-two percent (n = 8) of patients received chemotherapy. CONCLUSIONS: Penile cancer is a rare oncological condition that often requires bilateral inguinal ± pelvic lymph node dissection and should be managed according to published guidelines, in specialist centres in order to maximize outcomes.

Individual peer support: a qualitative study of mechanisms of its effectiveness.

Peer-delivered services for individuals with psychiatric conditions have proliferated over the past three decades. The values and principles underlying peer support have been explored, but we lack an understanding of its mechanisms of action. To shed light on the processes of peer support, we conducted a study with individuals who had received substantial individual peer support. We completed individual interviews, audiotaped, transcribed, and examined them using a thematic analysis approach. Our analyses suggest that individual peer support provided various practical, emotional, and social supports which were perceived as beneficial. Participants valued having someone to rely on, a friend, and someone to socialize with. We, however, found that individuals' expectations of peer support did not always comport with available services. Participants viewed peer support as especially valuable because of the opportunity for a non-treatment based, normalizing relationship. We conclude that peer support complements rather than supplants needed traditional mental health services.

Pattern of Change in Renal Function Following Radical Nephrectomy for Renal Cell Carcinoma.

Radical nephrectomy (RN) is an independent risk factor for the development of chronic kidney disease (CKD) in those with renal cell carcinoma (RCC). We aimed to examine the pattern of change in post-operative renal function in patients who underwent RN for RCC over a 3 year period at our institution. We performed a retrospective review of histological and biochemical findings in patients undergoing RN for RCC over a 38 month period. Estimated glomerular filtration rate (eGFR) was recorded pre- and post-operatively and at follow-up. We analysed data on 131 patients (median follow-up 24 months). The proportion of patients with advanced CKD increased significantly at follow-up with 48 (85.7%) patients, classified as having stage 2 CKD pre-operatively, being re-classified as stage 3-5. Mean eGFR was significantly lower pre-operatively (76.6 mL/min/1.73 m2) compared to hospital discharge (61 mL/min/1.73 m2, p < 0.001) and follow-up (55.5 mL/min/1.73 m2, p < 0.001). Those with pT1 tumours sustained a significantly greater decline in eGFR compared to other stages. In conclusion, patients with pT1 a and pT1 b tumours sustain a disproportionate decline in renal function and may benefit the most from NSS.

The course of toxicity in the pregnant mouse after exposure to the cyanobacterial toxin cylindrospermopsin: clinical effects, serum chemistries, hematology, and histopathology.

Cylindrospermopsin (CYN) is a toxin produced by a variety of fresh-water cyanobacterial species worldwide and induces significant adverse effects in both livestock and humans. This study investigated the course of CYN-induced toxicity in pregnant mice exposed daily during either the period of major organogenesis (gestation days [GD] 8-12) or fetal growth (GD13-17). Endpoints include clinical signs of toxicity, serum analyses to evaluate hepatic and renal function, histopathology of liver and kidney, and hematology. Study animals were administered 50 µg/kg CYN once daily by ip route and euthanized 24 h after 1, 2, 3, 4, or 5 consecutive doses, or 6 or 13 d after the dosing period. The course of the CYN-induced effects was determined at all euthanasia times for the endpoints just outlined. Results indicated that CYN is a toxin, producing lethality in dams during the early part of gestation, significant weight loss, and bleeding in the gastrointestinal tract, tail tip, and peri-orbital tissues. Effects also included alterations in serum markers for liver function, histopathological changes in liver and kidney tissues, electrolyte abnormalities, leukocytosis, and posttreatment thrombocytopenia and reticulocytosis. The onset of symptoms was rapid, producing reductions in weight gain in GD8-12 animals, bleeding in the vaginal area in GD13-17 animals, and significant increases in sorbitol dehydrogenase (SDH) in both groups after a single dose. Although the GD8-12 dams displayed a 50% lethality, in GD13-17 animals only a single death occurred. Alterations seen in hepatic and renal function or histopathology do not appear to be of sufficient severity to produce death. Evidence indicates that bleeding may play a critical role in the onset of symptoms and eventually, in the observed lethality.

Toll-like receptor-associated sequence variants and prostate cancer risk among men of African descent.

Recent advances demonstrate a relationship between chronic/recurrent inflammation and prostate cancer (PCA). Among inflammatory regulators, toll-like receptors (TLRs) have a critical role in innate immune responses. However, it remains unclear whether variant TLR genes influence PCA risk among men of African descent. Therefore, we evaluated the impact of 32 TLR-associated single-nucleotide polymorphisms (SNPs) on PCA risk among African Americans and Jamaicans. SNP profiles of 814 subjects were evaluated using Illumina's Veracode genotyping platform. Single and combined effects of SNPs in relation to PCA risk were assessed using age-adjusted logistic regression and entropy-based multifactor dimensionality reduction (MDR) models. Seven sequence variants detected in TLR6, TOLLIP (Toll-interacting protein), IRAK4 (interleukin-1 receptor-associated kinase 4) and IRF3 (interferon regulatory factor 3) were marginally related to PCA. However, none of these effects remained significant after adjusting for multiple hypothesis testing. Nevertheless, MDR modeling revealed a complex interaction between IRAK4 rs4251545 and TLR2 rs1898830 as a significant predictor of PCA risk among US men (permutation testing P-value=0.001). However, these findings require further assessment and validation.

"Digitally" addressable focusing of light into a subwavelength hot spot.

We show that a plasmonic metamaterial can act as a far-field to near-field transformer that focuses a free-space beam of light into a subwavelength energy hot spot at a prescribed location with a spot size only a small fraction of the wavelength. The hot spot position on the metamaterial can be prescribed and moved at will from one metamolecule of the array to another in a "digital" fashion simply by modulating the input phase profile, thus providing new opportunities for imaging and optical data processing.

Conceptualization and measurement of mental health providers' recovery-promoting competence: the recovery promoting relationships scale (RPRS).

OBJECTIVE: The purpose of this study was to construct and validate an instrument that measures practitioners' competence to promote the recovery among individuals with psychiatric disabilities from the perspective of the person served. Items were developed based upon input from individuals served and practitioners as well as the extant literature on recovery. "Recovery-promoting competence" was conceptualized as a set of practitioner capabilities that promote the recovery process and enhance the working alliance. METHOD: A scale was developed using a two-stage process that initially identified specific recovery-promoting competencies and then tested candidate items measuring those competencies. Item Response Theory and Classical Test Theory approaches were used to validate the instrument and assess its psychometric properties with a national sample of 382 individuals with psychiatric disabilities. RESULTS: Analyses revealed two distinct sets of recovery-promoting competencies: (a) competencies that enhance clients' recovery, and (b) competencies that build and maintain a strong therapeutic or working alliance. The first set further differentiated into subcompetencies-enhancing clients' hopefulness, empowerment, and self-acceptance. The instrument had high internal consistency and acceptable stability over time, convergent, criterion, and known groups' validity. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: This scale is a tool for assessing mental health and rehabilitation practitioners' competencies from the perspective of the individual served which can be used both in research and program evaluation of agencies serving individuals with psychiatric disabilities.