Errors of commission and omission in novice group counseling trainees' knowledge structures of group counseling situations.

This study investigated how novice group counseling trainees' knowledge structures about group situations differed from experts.' Eight highly experienced group therapists and 54 novice trainees indicated which of the 19 leader interventions they would consider using to respond to the 21 group situations described in the Group Therapy Questionnaire (GTQ, Wile, Bron, & Pollack, 1970). Pathfinder Network Analysis (Schvaneveldt, 1990) was used to generate knowledge structures (cognitive maps) about group situations based on the aggregated response of experts and each trainee's response to GTQ. Comparing trainees' maps with the referent expert map, we found no common errors of commission, that is, relationship between situations in trainees' knowledge maps but not in experts' knowledge maps, but 10 common errors of omission, that is, relationships among group situations in experts' knowledge maps but not in trainees' knowledge maps. Cluster analysis identified 2 subgroups of trainees. Neither of these trainee subgroups incorporated the group's developmental stage into their map of group situations as experts did: experts saw the situations during the beginning and ending phases of the group as similar but different from situations in the middle phase of the group. The first group of trainees had a holistic approach to group situations but tended to make errors in dealing with group situations involving a problematic member. The second group had an atomistic approach to group situations but lacked a clearly differentiated and structured general organization for the situations. They tended to make errors in dealing with challenging situations where the group is avoidant and lacks engagement.

Are Single-Item Global Ratings Useful for Assessing Health Status?

The research performance of the single-item self-rating In general, would you say your health is: excellent, very good, good, fair, or poor? was evaluated relative to the SF-36 General Health Scale that contains this item, using data for a sample of psychiatric outpatients who had co-occurring chronic physical conditions (N = 177). The scale was more robust than the single-item in cross-sectional validity tests and for predicting 2-year outcomes, but the single-item had stronger discriminant validity as a measure of physical health, especially in post-baseline analyses. Single-item and scale were both sensitive enough to detect change in perceived health over 2 years and a conditional experimental effect on health self-perceptions in a randomized trial. These findings demonstrate that a global single-item can be as valid, reliable, and sensitive as a multi-item scale for longitudinal research purposes, even if the scale performs better in cross-sectional surveys or as a screening measure.

Age and physical health as predictors of family contact among adults with severe psychiatric illness.

We assessed the association of frequency of family contact with age and physical health for a sample of adults with severe psychiatric illness (N = 171). This cross-sectional, observational study measured frequency of face-to-face and telephone contact with family members; satisfaction with family relations; and severity of participants' chronic or permanent physical health conditions. In this sample of adults with severe psychiatric illness, having a physical health condition and advancing age correlated negatively with frequency of face-to-face contact with family members. However, a hierarchical regression analysis controlling for residence in a family member's home, and participants' ratings of satisfaction with family relations, showed that the combination of being older and having more severe health conditions was associated with a more frequent rate of family contact than would be expected based on age or physical health considered alone. Because almost all older participants in this heterogeneous sample had serious physical health conditions, as well as frequent telephone and face-to-face contact with their family members, we recommend the recruitment of family members as collaborators in illness management interventions for aging and mid-life adults with psychiatric illness.

Social value of supported employment for psychosocial program participants.

Members of a psychiatric psychosocial program designed to provide both supported employment and peer support were surveyed about their current social activities, sources of social support, and social life improvement since joining the program. Survey respondents who worked a mainstream job (n=17) reported greater peer contact in community locations, and correspondingly greater social life improvement, than those who remained unemployed or worked volunteer jobs (n=45). Results of a hierarchical regression analysis (N=62) that explored this positive correlation between mainstream work, community-based peer contact, and social life satisfaction suggest that working a job in an integrated setting that paid at least minimum wage encouraged program participants to meet and interact in community locations, thereby strengthening peer mutual support while furthering social integration. This unique pattern of findings requires replication, and we recommend that other psychosocial programs conduct similar quality improvement studies to provide further insights into the relationship between peer support and community integration.

Adapting evidence-based interventions to fit usual practice: staff roles and consumer choice in psychiatric rehabilitation.

This proof-of-concept study tested the viability of adapting a specialized practice to fit multi-service programs by switching from specialist to generalist staff roles. The intervention under study was supported employment, an evidence-based practice for adults with severe mental illness. Program data on participant characteristics, attendance, staff contact, and employment were retrieved for the 2007 calendar year (N = 99). Two hierarchical regression analyses compared (1) participants with any versus no mainstream employment, and (2) participants who started a new job in 2007 versus all other participants. In both analyses, individual participant counts of days on which employment services were provided and count of different employment service providers independently predicted mainstream employment over and above program attendance and background factors. The study program's employment rate approximated rates published for specialized supported employment programs, suggesting that it is feasible to adapt specialized evidence-based practices to fit multi-service settings without compromising service quality.

Viability of using employment rates from randomized trials as benchmarks for supported employment program performance.

Cumulative employment rates published by randomized trials are based on each enrollee's pre-planned 18-24-months of study participation. By contrast, community programs typically report employment rates for clients active in services during a calendar quarter. Using data from three supported employment programs in randomized trials, we show that trial cumulative employment rates are about twice as large as quarterly employment rates for the same program. Therefore, we recommend that administrators, service networks, and mental health authorities begin to publish quarterly employment rates, and quarterly median earnings, to allow policymakers to set realistic performance expectations for supported employment programs.

Preference in random assignment: implications for the interpretation of randomized trials.

Random assignment to a preferred experimental condition can increase service engagement and enhance outcomes, while assignment to a less-preferred condition can discourage service receipt and limit outcome attainment. We examined randomized trials for one prominent psychiatric rehabilitation intervention, supported employment, to gauge how often assignment preference might have complicated the interpretation of findings. Condition descriptions, and greater early attrition from services-as-usual comparison conditions, suggest that many study enrollees favored assignment to new rapid-job-placement supported employment, but no study took this possibility into account. Reviews of trials in other service fields are needed to determine whether this design problem is widespread.

Choice of service provider: how consumer self-determination shaped a psychiatric rehabilitation program.

OBJECTIVE: To document the impact of consumer self-selection of service providers on their service receipt and attendance in a psychiatric rehabilitation program. METHODS: Staff (8 FTE) in a new drop-in resource center tracked their service activities and contacts with consumers using daily service logs. Consumers (N = 46) checked their service needs at enrollment, and recorded their attendance on daily sign-in sheets. Regression analyses were conducted to examine correlations between these service measures and each consumer's count of key providers, with key provider defined as any staff worker with whom the consumer logged the equivalent of more than a full workday of contact (9+ hours) during a 6-month study period. RESULTS: Service log findings suggest that key service providers were chosen by consumers through informal social interactions with staff. Members who had more key providers were more active in the program and more likely to have checked a need for psychiatric care at enrollment. In spite of member choice of provider, caseloads remained small and staff were able to dedicate their time to services related to their specialty training. CONCLUSIONS: Facility-based programs can encourage consumer self-selection of service providers without overloading staff or restricting specialty services if they provide ample time for staff and consumers to get to know one another in informal social interactions.

The employment intervention demonstration program: major findings and policy implications.

This article summarizes the published results of the Employment Intervention Demonstration Program (EIDP), a federally-funded, multi-site study examining the effectiveness of supported employment programs for 1273 unemployed individuals with psychiatric disabilities in the U.S. Findings confirm the effectiveness of supported employment across different models, program locations, and participant populations. The study's results are discussed in the context of public policies designed to encourage return to work for those with a severe mental illness.

It's complicated: Using group member process-feedback to improve group therapist effectiveness.

Experienced leaders of psychotherapy groups are surprisingly inaccurate in their judgments about their members' perceptions of positive bonding relationships with the leader and other group members. The practical implication is worrisome: the lower the leader's degree of accuracy, the worse the member therapeutic outcomes tend to be. A promising approach to improving leaders' appraisals of their members' perceptions of positive bonding relationships is to provide them, after each session, feedback about their own and their members' bonding relationship perceptions. Profiling trajectories of leaders' and members' perceptions over time yields rich "stories" of relationship development, that if strategically packaged into brief, concise, and vivid reports, and delivered as a formal "group member feedback" intervention, would direct leaders' attention to those emerging, but easily overlooked, countertherapeutic relationships, requiring immediate, well-informed targeted interventions. To increase the utility of such reports, training leaders use intuitively appealing, but structured heuristics ("interpersonal-fit-with-the-group" and "intrapersonal-split-relationships"), accelerate leaders' recognition of patterns in perceptions as they change over time, and free up their cognitive resources for determining whether to intervene into the group process at the appropriate level: intraindividual, interpersonal, or group-as-a-whole. To illustrate the use of these heuristics, we present two hypothetical cases, with visual displays of congruent and discrepant perceptions of bonding relationship perceptions between members over time, and make tentative recommendations about where and when leaders might intervene to achieve optimal impact. (PsycINFO Database Record

Randomized trial of supported employment integrated with assertive community treatment for rural adults with severe mental illness.

Urban-based randomized clinical trials of integrated supported employment (SE) and mental health services in the United States on average have doubled the employment rates of adults with severe mental illness (SMI) compared to traditional vocational rehabilitation. However, studies have not yet explored if the service integrative functions of SE will be effective in coordinating rural-based services that are limited, loosely linked, and geographically dispersed. In addition, SE's ability to replicate the work outcomes of urban programs in rural economies with scarce and less diverse job opportunities remains unknown. In a rural South Carolina county, we designed and implemented a program blending Assertive Community Treatment (ACT) with an SE model, Individual Placement and Support (IPS). The ACT-IPS program operated with ACT and IPS subteams that tightly integrated vocational with mental health services within each self-contained team. In a 24-month randomized clinical trial, we compared ACT-IPS to a traditional program providing parallel vocational and mental health services on competitive work outcomes for adults with SMI (N = 143; 69% schizophrenia, 77% African American). More ACT-IPS participants held competitive jobs (64 versus 26%; p < .001, effect size [ES] = 0.38) and earned more income (median [Mdn] = 549 US dollars, interquartile range [IQR] = 0-5,145 US dollars, versus Mdn = 0 US dollars, IQR = 0-40 US dollars; p < .001, ES = 0.70) than comparison participants. The competitive work outcomes of this rural ACT-IPS program closely resemble those of urban SE programs. However, achieving economic self-sufficiently and developing careers probably require increasing access to higher education and jobs imparting marketable technical skills.

Results of a multisite randomized trial of supported employment interventions for individuals with severe mental illness.

CONTEXT: National probability surveys indicate that most individuals with schizophrenia and other severe mental illnesses are not employed. This multisite study tested the effectiveness of supported employment (SE) models combining clinical and vocational rehabilitation services to establish competitive employment. METHODS: We randomly assigned 1273 outpatients with severe mental illness from 7 states in the United States to an experimental SE program or to a comparison or a services-as-usual condition, with follow-up for 24 months. Participants were interviewed semiannually, paid employment was tracked weekly, and vocational and clinical services were measured monthly. Mixed-effects random regression analysis was used to predict the likelihood of competitive employment, working 40 or more hours in a given month, and monthly earnings. RESULTS: Cumulative results during 24 months show that experimental group participants (359/648 [55%]) were more likely than those in the comparison programs (210/625 [34%]) to achieve competitive employment (chi(2) = 61.17; P<.001). Similarly, patients in experimental group programs (330/648 [51%]) were more likely than those in comparison programs (245/625 [39%]) to work 40 or more hours in a given month (chi(2) = 17.66; P<.001). Finally, participants in experimental group programs had significantly higher monthly earnings than those in the comparison programs (mean, US 122 dollars/mo [n=639] vs US 99 dollars/mo [n=622]); t(1259) = -2.04; P<.05). In the multivariate longitudinal analysis, experimental condition subjects were more likely than comparison group subjects to be competitively employed, work 40 or more hours in a given month, and have higher earnings, despite controlling for demographic, clinical, work history, disability beneficiary status, and study site confounders. Moreover, the advantage of experimental over comparison group participants increased during the 24-month study period. CONCLUSION: The SE models tailored by integrating clinical and vocational services were more effective than services as usual or unenhanced services.

Estimated payments to employment service providers for persons with mental illness in the Ticket to Work program.

OBJECTIVE: The Ticket to Work and Work Incentives Improvement Act of 1999 removes work disincentives and promotes access to vocational services for people with disabilities. This study calculated the amount of payments that would have been made to employment service providers if study participants had been enrolled in the Ticket program. METHODS: Data were from 450 Social Security Disability Insurance beneficiaries with psychiatric disabilities enrolled in a multisite study of supported employment. Earnings over two years were used to calculate provider payments under two reimbursement formulas used in the Ticket program. RESULTS: Only a quarter of service recipients (26 percent) reached earnings levels that would have triggered provider payments under the first reimbursement formula. Only 4 percent would have completed their trial work period and left the rolls, generating payments under the second formula. CONCLUSIONS: The current provider payment systems of the Ticket to Work program do not reflect the reality of rehabilitation for individuals with severe mental illness. Reforms should take into account outcomes of return-to-work services for this population.

Challenges to implementing and sustaining comprehensive mental health service programs.

The President's New Freedom Commission recently concluded that the nation's mental health service delivery system is ill equipped to meet the complex needs of persons with mental illness. A major contributor to this service quality crisis has been the longstanding divergence of research efforts and clinical programs. In this article, the authors begin by describing the unique needs of persons with serious and persisting psychiatric disorders and the evolution of the mental health service system that has attempted to meet these needs. They then discuss recent efforts to upgrade services by emphasizing the use of evidence-based practices (EBPs) and the research underlying their development. Next, they describe the difficulties of using traditional research methods to develop and test interventions for persons receiving services at public mental health agencies. Finally, they outline the challenges confronted when trying to disseminate these EBPs to the wider clinical community.

Does Competitive Work Improve Quality of Life for Adults with Severe Mental Illness? Evidence from a Randomized Trial of Supported Employment.

A randomized trial comparing a facility-based Clubhouse (N = 83) to a mobile Program of Assertive Community Treatment (PACT; N = 84) tested the widely held belief that competitive employment improves global quality of life for adults with severe mental illness. Random regression analyses showed that, over 24 months of study participation, competitively employed Clubhouse participants reported greater global quality of life improvement, particularly with the social and financial aspects of their lives, as well as greater self-esteem and service satisfaction, compared to competitively employed PACT participants. However, there was no overall association between global quality of life and competitive work, or work duration. Future research will determine whether these findings generalize to other certified Clubhouses or to other types of supported employment. Multi-site studies are needed to identify key mechanisms for quality of life improvement in certified Clubhouses, including the possibly essential role of Clubhouse employer consortiums for providing high-wage, socially integrated jobs.

Integration of psychiatric and vocational services: a multisite randomized, controlled trial of supported employment.

OBJECTIVE: Although large-scale surveys indicate that patients with severe mental illness want to work, their unemployment rate is three to five times that of the general adult population. This multisite, randomized implementation effectiveness trial examined the impact of highly integrated psychiatric and vocational rehabilitation services on the likelihood of successful work outcomes. METHOD: At seven sites nationwide, 1,273 outpatients with severe mental illness were randomly assigned either to an experimental supported employment program or to a comparison/services-as-usual condition and followed for 24 months. Data collection involved monthly services tracking, semiannual in-person interviews, recording of all paid employment, and program ratings made by using a services-integration measure. The likelihood of competitive employment and working 40 or more hours per month was examined by using mixed-effects random regression analysis. RESULTS: Subjects served by models that integrated psychiatric and vocational service delivery were more than twice as likely to be competitively employed and almost 1(1/2) times as likely to work at least 40 hours per month when the authors controlled for time, demographic, clinical, and work history confounds. In addition, higher cumulative amounts of vocational services were associated with better employment outcomes, whereas higher cumulative amounts of psychiatric services were associated with poorer outcomes. CONCLUSIONS: Supported employment models with high levels of integration of psychiatric and vocational services were more effective than models with low levels of service integration.

Prevalence of posttraumatic stress disorder in Veterans Affairs primary care clinics.

Although posttraumatic stress disorder (PTSD) is relatively common in community epidemiologic surveys (5-6% for men, 10-12% for women), and psychiatric patients with PTSD are known to have poor functioning and high levels of psychiatric comorbidity, there are no studies that address PTSD prevalence, functioning, and burden in primary care settings. This article reports on (1) the prevalence of PTSD using Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition diagnostic criteria in Veterans Affairs (VA) primary care settings, (2) associated sociodemographic characteristics and comorbidities, (3) functional status related to PTSD, (4) the extent to which PTSD was recognized by providers and (5) health services use patterns (including specialty mental health) of PTSD patients. Patients were randomly selected from those who had an outpatient visit in FY 1999 at one of four VA hospitals; 888 patients consented (74.1% of 1198 contacted); 746 patients (84.0% of consenting patients; 62.3% of contacted patients) were reached for telephone diagnostic interviews. Diagnostic interviews with the Clinician Administered PTSD Scale yielded estimates of current PTSD prevalence of 11.5%. At statistically significant levels, PTSD was positively associated with a variety of comorbid psychiatric disorders, war zone service, age <65 years, not working, less formal education and decreased functioning. Of patients diagnosed with PTSD by study procedures, 12-month medical record review indicated that providers identified only 46.5% and only 47.7% had used mental health specialty services. PTSD-positive [PTSD(+)] patients who used mental health care in the past 12 months were more apt to be identified as having PTSD than nonmental health service users (78.0% vs. 17.8%). Although PTSD(+) patients had more medical record diagnoses than PTSD-negative [PTSD(-)] patients (6.28 vs. 4.95), their use of primary care, urgent care and inpatient care was not different from PTSD(-) patients.

Effects of job development and job support on competitive employment of persons with severe mental illness.

OBJECTIVES: Few studies have sought to determine which specific supported employment services improve employment outcomes for people with pyschiatric disabilities. This study examined the effects of job development and job support among other services on acquisition and retention of competitive employment. METHODS: Data used in the analysis came from seven sites of the Employment Intervention Demonstration Program. Employment data were collected weekly for a period up to 24 months for 1,340 participants. A random-effects meta-analysis was conducted. RESULTS: Job development increased the probability of obtaining competitive employment. The effects of job development on job acquisition remained after the effects of other factors were controlled for. Job support was associated with more months in the first competitive job but not total hours worked. However, no evidence for the causal role of job support was found in analyses that tested the effects of job support after the job support was provided. The causal role of job support alone was also cast in doubt by the fact that a substantial overlap existed between individuals who received job support and vocational counseling. CONCLUSIONS: Job development is a very effective service when the goal is job acquisition. Job support is associated with retention of a first competitive job, but its causal role is questionable.

Screening offenders with histories of mental illness and violence for supportive housing.

This article describes a community mental health agency's process of screening supportive housing applicants with histories of violent felonies and serious mental illness. The agency adopted its corporate intranet as a tool so that geographically dispersed senior staff could participate in information gathering in order to ensure expert input in admissions decisions. This broad-based participation was designed to maintain community safety, while making the agency's residential resources available to people with mental illness and criminal histories. Considering the high recidivism rate of ex-offenders with mental illness and lack of clearly established best practices to serve them in the community, the authors believe that it is timely for housing providers to reevaluate how to better serve these individuals.

Comparison of self-report versus agency records of service utilization in a community sample of individuals with alcohol use disorders.

Health services research has become an important area for evaluating the cost effectiveness of interventions. When used in treatment outcome research, the accuracy of self-report data is essential. The reliability and validity of self-report service utilization among alcohol and drug addicted individuals is questionable and largely unexplored. This study assessed the accuracy of self-report utilization of services compared to service record abstraction in a sample of treatment seeking individuals with alcohol use disorders. The results of the comparative analysis found that the level of agreement for some services, particularly medical, psychiatric and substance abuse inpatient admissions, and social service involvement was good. There was less agreement in emergency room visits and arrests. Factors related to discrepancies between self-report and records were explored.