Experiences of Clients and Professionals with the Recovery Oriented Intake.

The Recovery Oriented Intake (ROI) integrates recovery principles from the start of treatment, and involves peer experts, unlike the intake as usual (IAU). This study compared experiences with ROI and IAU among 127 clients and 391 professionals, consisting of practitioners and peer experts. Intake's quality, measured with questionnaires, showed no differences in experiences between ROI and IAU clients. However, practitioners experienced ROI as more recovery-oriented than IAU. The ROI Fidelity Check (RFC) revealed that clients' RFC-scores, but not practitioners', predicted their valuation of intake's quality. This underscores the need for (re)training and peer supervision for professionals to ensure adherence to ROI's principles. Discrepancies between clients' and professionals' experiences at the start of treatment are consistent with literature on working alliance and Shared Decision Making (SDM). Differences between ROI and IAU professionals may stem from heightened awareness of recovery principles due to training and the presence of peer experts during intake.

Recovery for all in the community; position paper on principles and key elements of community-based mental health care.

BACKGROUND: Service providers throughout Europe have identified the need to define how high-quality community-based mental health care looks to organize their own services and to inform governments, commissioners and funders. In 2016, representatives of mental health care service providers, networks, umbrella organizations and knowledge institutes in Europe came together to establish the European Community Mental Health Services Provider (EUCOMS) Network. This network developed a shared vision on the principles and key elements of community mental health care in different contexts. The result is a comprehensive consensus paper, of which this position paper is an outline. With this paper the network wants to contribute to the discussion on how to improve structures in mental healthcare, and to narrow the gap between evidence, policy and practice in Europe. MAIN TEXT: The development of the consensus paper started with an expert workshop in April 2016. An assigned writing group representing the workshop participants built upon the outcomes of this meeting and developed the consensus paper with the input from 100 European counterparts through two additional work groups, and two structured feedback rounds via email. High quality community-based mental health care: 1) protects human rights; 2) has a public health focus; 3) supports service users in their recovery journey; 4) makes use of effective interventions based on evidence and client goals; 5) promotes a wide network of support in the community and; 6) makes use of peer expertise in service design and delivery. Each principle is illustrated with good practices from European service providers that are members of the EUCOMS Network. CONCLUSIONS: Discussion among EUCOMS network members resulted in a blueprint for a regional model of integrated mental health care based upon six principles.

Outcomes of FLEXIBLE Assertive Community Treatment (FACT) Implementation: A Prospective Real Life Study.

This study aimed to investigate social and clinical outcomes and use of care during and after implementation of FLEXIBLE Assertive Community Treatment (ACT). Three teams and 372 patients were involved. Model fidelity, clinical and social assessments were performed at baseline and after 1 and 2 years. Use of care was registered continuously. Model fidelity was good at the end of the study. Data showed much variation between patients in number and duration of ACT periods. Statistically significant improvements were found in compliance, unmet needs and quality of life. Improvement of quality of life and functioning was related to duration of ACT. The percentage of remissions increased with 9 %. The number of admissions, admission days and face to face contacts differed between ACT and non-ACT patients, but generally decreased. Findings suggest that implementation of FACT results in a more flexible adaptation of care to the needs of the patients.

The role of national policies and mental health care systems in the development of community care and community support: an international analysis.

BACKGROUND: The development of adequate community support of persons with severe mental health problems is an ongoing effort. National policies and national health and social care systems play an important role in the effectiveness of these efforts. AIMS: To get a better understanding of the ways in which national policies and (mental) health care systems can enhance the development of community support and social inclusion for people with severe mental illness. METHOD: A comparison was made between the experiences of 75 key persons on regional community support development regarding national policies and systems in Denmark, England and the Netherlands respectively. RESULTS: Four themes stood out as being particularly instrumental in the development of community support: - implementation of a national policy on social inclusion, - development of a national framework of responsibilities, entitlements and services, - solid funding and social inclusion incentivizing reimbursement systems, - integrated care. CONCLUSION: National governments do have opportunities to take or retake the lead to ensure that community support and social inclusion of persons with severe mental illness health problems are not just ideological slogans but solid policy.

A pre-post study design: evaluating the effectiveness of a new community-based integrated service model on patient outcomes.

This study aimed to evaluate a new service model, Specialists Together In the Community (STIC), in terms of patient outcomes. This model integrates Flexible Assertive Community Treatment (FACT)-principles with expertise of specialized teams that offer diagnosis-related outpatient treatment. In a pre-post design, symptoms and quality of life of 930 former FACT-patients were measured repeatedly pre- and post-STIC. Regarding patients in former specialized teams, pre- and post-treatment social functioning and symptoms were measured for the pre- (n = 944) and post-STIC (n = 544) groups. Against expectation, symptoms of former FACT-patients remained stable post-STIC compared to a slight decrease pre-STIC. According to expectation, pre- and post-STIC groups had an equal symptom reduction. Unexpectedly, the post-STIC group did not improve more on social functioning than the pre-STIC group. Explorative analysis showed less treatment contacts in the post-STIC group. The highly similar patient outcomes post-STIC could be improved by monitoring process outcomes and prolonging study duration.

Effectiveness of Resource Groups for Improving Empowerment, Quality of Life, and Functioning of People With Severe Mental Illness: A Randomized Clinical Trial.

Importance: Although the importance of recovery-oriented care for people with severe mental illness (SMI) is widely acknowledged, essential elements such as personalization and involvement of significant others are not adequately implemented in practice. Objective: To determine whether using resource groups (RGs) within flexible assertive community treatment (FACT) has favorable effects on empowerment and recovery-related outcomes in people with SMI. Design, Setting, and Participants: This assessor-blind, multisite randomized clinical trial was conducted from September 1, 2017, to September 30, 2020, with follow-up at 9 and 18 months. A total of 158 participants aged 18 to 65 years meeting the criteria for SMI were randomly allocated to FACT plus RG vs FACT as usual (1:1) in 20 FACT teams throughout the Netherlands. Data were analyzed from September 1, 2020, to January 31, 2021. The study was prespecified in the trial protocol and data from the intent-to-treat population were analyzed. Interventions: In the FACT plus RG condition, patients chose members from their informal and formal networks to form an RG that meets quarterly to discuss self-formulated recovery goals. The RG was integrated into the multidisciplinary support provided by the FACT team. In the FACT as-usual condition, empowerment (defined as overcoming powerlessness and gaining control of one's life) and involvement of significant others was also part of the provided care, but without the structure of the RG. Main Outcomes and Measures: The primary outcome was self-reported empowerment, measured with the Netherlands Empowerment List. Results: A total of 158 participants with SMI (median age, 38 [median absolute deviation, 13] years; 93 men [58.9%]) were randomized to FACT plus RG (n = 80) or FACT as usual (n = 78) care. Intention-to-treat analyses showed that randomization to the RG condition was associated with a clinically significant increase in empowerment (Cohen d, 0.54; 95% CI, 0.21-0.86) and improved outcomes with small to medium effect sizes in terms of quality of life (Cohen d, 0.25; 95% CI, -0.07 to 0.56), personal recovery (Cohen d, 0.38; 95% CI, 0.06-0.69), quality of social contact (Cohen d, 0.24; 95% CI, -0.07 to 0.56), disability (Cohen d, 0.29; 95% CI, -0.03 to 0.60), general functioning (Cohen d, 0.30; 95% CI, -0.01 to 0.62), and social functioning (Cohen d, 0.28; 95% CI, -0.04 to 0.59). No differences between conditions were found regarding psychopathological symptoms, attachment, frequency of social contact, and employment. Compared with FACT as usual, participants who stayed with the assigned treatment in the RG condition were more satisfied with treatment at 9 (Cohen d = 0.45; t135 = -2.62; P = .009) and 18 (Cohen d = 0.41; t116 = -2.22; P = .02) months. Conclusions and Relevance: These findings show that working with RGs improves empowerment and other mental health outcomes in people with SMI who receive community-based mental health services. This method of network-oriented care empowers people with SMI within their own environment. Trial Registration: Netherlands Trial Register Identifier: NL6548.

Service User Experiences of How Flexible Assertive Community Treatment May Support or Inhibit Citizenship: A Qualitative Study.

The aim of this study was to explore and describe service user experiences of how receiving services from a Flexible Assertive Community Treatment (FACT) team may support or inhibit citizenship. Within a participatory design, individual interviews with 32 service users from five Norwegian FACT teams were analyzed using thematic, cross-sectional analysis. The findings showed that FACT may support citizenship by relating to service users as whole people, facilitating empowerment and involvement, and providing practical and accessible help. Experiences of coercion, limited involvement and authoritarian aspects of the system surrounding FACT had inhibited citizenship for participants in this study.

Mental health system reform in Moldova: Description of the program and reflections on its implementation between 2014 and 2019.

In 2014, the Republic of Moldova started a systematic process of reforming its mental health system, implementing priority actions set out in the National Mental Health Programme. The reform entailed a service delivery re-design, instituting mechanisms for collaboration across health and social sectors, and revision of the policy framework. Outcomes of the first 4 years of the reform included: 1) the establishment of a network of mental health services in 4 pilot districts embedding mental health diagnosis, treatment and referral in primary and specialized mental healthcare; 2) creation of an enabling policy environment at the national and district level; and 3) strengthened community support and acceptance of mental health issues. Objectives of the first Phase were achieved and the reform is now in its second Phase (2018-2022). The implementation strategy in Phase 1 focused efforts on 4 pilot districts, whereas Phase 2 harnesses lessons learned from Phase 1 and facilitates local leaders and actors to scale-up the model to all 32 districts and municipalities in Moldova. Ownership over the reform process shifted from project-led in Phase 1 to national and local government-led in Phase 2. We reflect on the process and contents of the mental health reform, discuss lessons learned and implementation challenges encountered. We conclude with learning points for policymakers and researchers considering mental health reform in other countries.

The resource group method in severe mental illness: study protocol for a randomized controlled trial and a qualitative multiple case study.

BACKGROUND: The resource group method provides a structure to facilitate patients' empowerment and recovery processes, and to systematically engage significant others in treatment and care. A patient chooses members of a resource group (RG) that will work together on fulfilling patients' recovery plan. By adopting shared decision-making processes and stimulating collaboration of different support systems, a broad and continuous support of patients' chosen goals and wishes is preserved and problem solving and communication skills of the RG members are addressed. OBJECTIVE: The objectives of this study are (1) to establish the effectiveness of the RG method in increasing empowerment in patients with severe mental illnesses (SMI) in the Netherlands; (2) to investigate the cost-effectiveness and cost utility of the RG method; and (3) to qualitatively explore its dynamics and processes. METHODS/DESIGN: This multisite randomized controlled trial will compare the effects of the RG-method integrated in Flexible Assertive Community Treatment (FACT) (90 patients) with those of standard FACT (90 patients). Baseline assessments and 9-month and 18-month follow-up assessments will be conducted in face-to-face home visits. The primary outcome measure, empowerment, will be assessed using the Netherlands Empowerment List (NEL). The secondary outcomes will be quality of life (MANSA); personal, community and clinical recovery (I.ROC); general, social and community functioning (WHODAS 2.0); general psychopathological signs and symptoms (BSI-18); and societal costs (TiC-P). An economic evaluation of the cost-effectiveness and cost utility of the RG method will also be conducted. A qualitative multiple case-study will be added to collect patients', RG members' and professionals' perspectives by in-depth interviews, observations and focus groups. DISCUSSION: This trial will be the first to study the effects of the RG method on empowerment in patients with SMI. By combining clinical-effectiveness data with an economic evaluation and in-depth qualitative information from primary stakeholders, it will provide a detailed overview of the RG method as a mean of improving care for patients with SMI.Trial registration The study has been registered in the Dutch Trial Register, identifier: NTR6737, September 2017.

Functional recovery of individuals with serious mental illnesses: Development and testing of a new short instrument for routine outcome monitoring.

OBJECTIVE: This article describes the development and testing of the Functional Recovery tool (FR tool), a short instrument for assessing functional recovery during routine outcome monitoring of people living with serious mental illnesses. METHODS: To assess functional recovery, mental health professionals conducted semistructured interviews with people living with serious mental illnesses on three areas of social functioning: daily living and self-care, work and study, and social contacts. Functioning in each of these areas over the past 6 months was rated on a 3-point scale: 0 (independent), 1 (partially independent), and 2 (dependent). The dichotomous overall outcome of the tool is defined as independent functioning in all areas. We analyzed interrater and test-retest reliability, sensitivity to change, and correlations with constructs that are assumed to be similar to the FR tool (quality of life in daily living, work, and social contacts) or divergent from it (symptomatic functioning). RESULTS: The FR tool was administered to 840 individuals with serious mental illnesses in Dutch mental health care services, 523 of whom were followed up for 1 year (response rate 62%). The tool was easy to complete and was appropriate for policy evaluation and practice. However, when it was combined with more elaborate instruments, it added little extra clinical information. Interrater and test-retest reliability, convergent and discriminant validity, and sensitivity to change were rated sufficient to good. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: The FR tool could be a useful measure of functional recovery in addition to current measures of symptomatic remission and personal recovery in routine outcome monitoring. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Feasibility of teaching motivational interviewing to parents of young adults with recent-onset schizophrenia and co-occurring cannabis use.

This study examined the feasibility of providing motivational interviewing (MI) training to parents of young adults with recent-onset schizophrenia and co-occurring cannabis use. The training was offered in a mental health care setting as part of a family motivational intervention (FMI). Ninety-seven parents were randomly assigned to either FMI or routine family support (RFS). To obtain a measure of parent's MI skills at baseline and 3 months after they completed FMI, their role-play interactions with an actor portraying their child were coded. The coding method had satisfactory inter-rater reliability and internal consistency. At follow-up, parents in FMI showed significantly greater adherence to (p=.03) and competence in (p=.04) MI than parents in RFS. Parents in FMI also demonstrated significantly greater increases in expressing empathy (p=.01). These results demonstrate that FMI is a feasible method for increasing MI skills in parents. Additional research is needed to better understand the unique application of MI to parent-child interactions.