Learning from women veterans who navigate invisible injuries, caregiving, and reintegration challenges.

BACKGROUND: As women comprise a greater proportion of military service members, there is growing recognition of how their experiences in the early phase of military to civilian transitions have an important influence on their health and reintegration outcomes. Qualitative accounts of women veterans can inform programs that support transitioning service members. OBJECTIVES: We examined narratives of civilian reintegration among women veterans to understand their experiences of adjusting to community life while coping with mental health challenges. METHODS/PARTICIPANTS: We interviewed 16 post-911 era women who were within 5 years of separating from military service and developed a case study based on three participants. MAIN APPROACH: Interviews were audio-recorded and transcribed verbatim. Inductive thematic analysis was conducted to establish categories about reintegration. Immersion/crystallization techniques were used to identify exemplary cases that illustrated salient themes. KEY RESULTS: Women veterans identified establishing a future career direction, drawing on social support, and navigating health care services as major factors influencing how they adjusted to civilian life. In addition, participants also highlighted the navigation of complex and intersecting identities (i.e., wife, mother, employee, friend, veteran, patient, etc.), further magnified by gender inequalities. These women performed emotional labor, which is often rendered invisible and oriented toward their family and loved ones, while simultaneously monitoring self-care activities. During the early period of reintegration, they described how they felt marginalized in terms of accessing healthcare compared to their military spouses and male veteran peers. CONCLUSIONS: Our case study suggests that there are key gaps in addressing healthcare and readjustment needs for women servicemembers, a high priority VA group, as they transition into post-military life. It is important to consider innovative ways to address specific needs of women in veteran-focused policies and programs.

Contrasting Metacognitive, Emotion Recognition and Alexithymia Profiles in Bulimia, Anorexia, and Schizophrenia.

ABSTRACT: Alexithymia, or deficits in emotion recognition, and metacognitive capacity have been noted both in psychosis and eating disorders and potentially linked to psychopathology. This study sought to compare levels of impairments in these phenomena and their associations with psychopathology in groups with eating disorders and psychosis. Participants with diagnoses of a schizophrenia spectrum disorder (SSD; n = 53), anorexia (n = 40), or bulimia (n = 40) were recruited from outpatient clinics. Alexithymia was measured with the Toronto Alexithymia Scale; emotion recognition, with the Ekman Faces Test; and metacognition, with the Metacognitive Assessment Scale-Abbreviated. Psychopathology was measured with the Eating Attitudes Test, Body Image Questionnaire, and Positive and Negative Syndrome Scale. Results indicated that the SSD group had significantly poorer metacognitive function than either eating disorder group. Metacognition was related to body image in the anorexia group and a range of different forms of general psychopathology in the bulimia group. Alexithymia was related to eating disorder behaviors in the bulimia group.

Exploring Factors Impacting the Implementation of Recovery-Oriented Treatment Planning on Acute Inpatient Mental Health Units.

PURPOSE: The current literature on operationalizing and implementing recovery-oriented inpatient care in diverse settings remains limited. The present study systematically examined factors affecting the implementation of one aspect of recovery-oriented care in a large and diverse national sample of Veterans Health Administration (VHA) inpatient mental health units. METHOD: VHA inpatient mental health units were scored on the Recovery-Oriented Acute Inpatient scale (RAIN). Sites scoring either one standard deviation above (n = 8; i.e., high-scoring sites) or one standard deviation below (n = 5; i.e., low-scoring sites) the mean on the RAIN factor of inpatient treatment planning subscale were included for additional analyses (N = 13). We used a qualitative approach known as emergent thematic analysis to assess the implementation of inpatient treatment planning elements (e.g., goal setting, shared decision-making) from qualitative interviews, observation notes, and chart reviews collected for the 13 sites. The analysis was guided by Normalization Process Theory. RESULTS: The eleven themes that emerged across the elements of recovery-oriented inpatient treatment planning mostly represented commonalities across sites, such as a shared treatment philosophy of acute care. However, five themes emerged as "differentiators" that distinguished high- and low-scoring sites and included veteran input, elicitation of recovery goals, the value of group programming, and the purpose of family involvement. CONCLUSION: Findings provide insight into contextual factors and processes that impacted the implementation of recovery-oriented treatment planning at these VHA inpatient mental health units. To further facilitate the implementation of recovery-oriented inpatient treatment planning elements, future research should examine staff's collective understanding of recovery-oriented inpatient care.

Total Metacognitive Capacity Predicts Competitive Employment Acquisition Across 6 Months in Adults With Serious Mental Illness Receiving Psychiatric Rehabilitation Services.

ABSTRACT: Deficits in metacognitive capacity are common among people with serious mental illness (SMI), although there is a gap in knowledge regarding how these impairments predict later functioning, especially employment. This study aimed to prospectively examine the relationship between metacognitive capacity and 6-month competitive employment attainment in adults with SMI who were participating in a study testing a cognitive behavioral therapy intervention added to supported employment services. Sixty-seven participants with complete data at baseline and the 6-month follow-up comprised the sample. Data were analyzed using stepwise logistic regression covarying for work history and study assignment. Results indicate that total metacognitive capacity at baseline significantly predicted employment acquisition at 6 months; the final model correctly classified 83.3% of participants who obtained work. In conclusion, these findings suggest that better overall metacognitive capacity may be key for future work functioning. Thus, interventions that target metacognitive capacity may lead to enhancements in community outcomes.

Psychosocial outcomes of a pilot study of work-tailored cognitive behavioral therapy intervention for adults with serious mental illness.

OBJECTIVE: Many people with serious mental illness (SMI) continue to struggle with work functioning despite the receipt of supported employment (SE) services. In response, adjunctive interventions to SE have begun to be developed. One such approach, the cognitive behavioral therapy for work success (CBTw) intervention, targets cognitive and behavioral barriers to competitive work success in adults with SMI. Using a pre-post design, this pilot study examined the psychosocial outcomes of the CBTw program in 52 adults with SMI receiving SE. METHOD: Recovery attitudes, work-related self-efficacy, self-esteem, and symptom domains (depression, anxiety, psychosis) were measured at baseline and after the 12-week intervention. Paired samples t-tests examined changes in outcomes over time. RESULTS: At posttreatment, participants had significant improvements in recovery attitudes, self-esteem, depressive, and negative symptoms. Other psychosocial outcomes did not significantly change. CONCLUSIONS: This pilot work demonstrates CBTw is a promising intervention to improve recovery and wellness in SMI.

The association of metacognition with emotion recognition and perspective taking in a Russian sample with psychosis.

OBJECTIVE: Schizophrenia may reflect an interactive network of disturbances in cognition. In this study we have examined the relationship between two forms of cognition: metacognition and social cognition among a sample with schizophrenia (n = 41), early episode psychosis (n = 37), and major depression (n = 30) gathered in Moscow, Russia. METHODS: Metacognition was assessed with the Metacognition Assessment Scale-Abbreviated. Social cognition was assessed with the Ekman 60 Faces Test and the Interpersonal Reactivity Index. Verbal memory and global psychopathology were included as potential covariates. RESULTS: Partial correlations controlling for demographics, neurocognition, and psychopathology revealed greater metacognitive capacity was linked to better facial emotion recognition and perspective taking in the prolonged schizophrenia group. Greater metacognitive capacity in the early psychosis group was linked with greater facial emotion recognition. Metacognition and social cognition were not related to one another in the depression group. CONCLUSIONS: Social cognition and metacognition may be uniquely related in psychosis.

A National Survey of Patient Completion of Cognitive Behavioral Therapy for Chronic Pain: The Role of Therapist Characteristics, Attempt Rates, and Modification.

The implementation of evidence-based psychotherapies, including patient-level measures such as penetration and rates of successfully completing a course of therapy, has received increasing attention. While much attention has been paid to the effect of patient-level factors on implementation, relatively little attention has been paid to therapist factors (e.g., professional training, experience). OBJECTIVE: The current study explores therapists' decisions to offer a particular evidence-based psychotherapy (cognitive behavioral therapy for chronic pain; CBT-CP), whether and how they modify CBT-CP, and the relationship between these decisions and patient completion rates. METHODS: The study utilized survey responses from 141 Veterans Affairs therapists certified in CBT-CP. RESULTS: Therapists reported attempting CBT-CP with a little less than one half of their patients with chronic pain (mean = 48.8%, s.d.=35.7). Therapist were generally split between reporting modifying CBT-CP for either very few or most of their patients. After controlling for therapist characteristics and modification, therapist-reported percentage of patients with attempted CBT-CP was positively associated with completion rates, t (111) = 4.57, p<.001. CONCLUSIONS: Therapists who attempt CBT-CP more frequently may experience better completion rates, perhaps due to practice effects or contextual factors that support both attempts and completion. Future research should examine this relationship using objective measures of attempt rates and completion.

Peer Support for Self-Management of Chronic Pain: the Evaluation of a Peer Coach-Led Intervention to Improve Pain Symptoms (ECLIPSE) Trial.

BACKGROUND: Pain self-management is an effective, evidence-based treatment for chronic pain. Peer support, in which patients serve as coaches for other patients, has been effective in other chronic conditions and is a potentially promising approach to implementing pain self-management programs using fewer clinical resources. OBJECTIVE: To test a peer coach-delivered pain self-management program for chronic pain. DESIGN: Randomized controlled trial. PARTICIPANTS: Veterans with chronic musculoskeletal pain. INTERVENTION: Intervention patients were assigned a trained peer coach for 6 months. Coaches, who were volunteers, were asked to contact their assigned patients, either by phone or in person, twice per month. Coaches and patients were given an intervention manual to guide sessions. The control group was offered a 2-hour pain self-management class. MAIN MEASURES: The primary outcome was total pain, assessed by the Brief Pain Inventory (BPI). Secondary outcomes were anxiety, depression, pain catastrophizing, self-efficacy, social support, patient activation, health-related quality of life, and healthcare utilization. Outcomes were measured at baseline, 6 months, and 9 months. KEY RESULTS: Two hundred fifteen patients enrolled (120 intervention, 95 control). Adherence to intervention protocol was low, with only 13% of patients reporting having at least the recommended 12 peer coach meetings over the 6-month intervention. BPI total decreased from baseline to 6 months and baseline to 9 months in both groups. At 9 months, this change was statistically significant (intervention, - 0.40, p = 0.018; control, - 0.47, p = 0.006). There was not a statistically significant difference between groups on BPI at either time point. No secondary outcomes improved significantly in either group after adjusting for multiple comparisons. CONCLUSIONS: Patients randomized to peer support did not differ from control patients on primary and secondary outcomes. Other peer support models that do not rely on volunteers might be more effective. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02380690.

Dynamic relationships between emotional distress, persecutory ideation, and metacognition in schizophrenia.

OBJECTIVE: Determine whether metacognitive capacity (i.e., a range of abilities that involve recognition, reflection, and integration of mental states) influences the relationships between emotional distress and persecutory ideation (PI). METHODS: The present study examined emotional distress, metacognition and PI in a sample (n = 337) of individuals with schizophrenia or schizoaffective disorder and clinician-rated PI. Pearson and partial correlations were used to examine relationships between variables, as well as between-subjects analysis of variances to compare groups characterized based on emotional distress and persecutory ideation scores. RESULTS: While emotional distress and PI are associated with one another, metacognition is negatively associated with PI and positively associated with emotional distress. Subgroup comparisons demonstrated that individuals with high emotional distress and low PI had significantly higher metacognitive capacity than those elevated in PI or reduced in both emotional distress and PI. CONCLUSIONS: Findings suggest metacognitive capacity may relate to improved awareness of distress and reduced PI.

A Pilot Test of Group Based Cognitive Behavioral Therapy to Augment Vocational Services for Persons With Serious Mental Illness: Feasibility and Competitive Work Outcomes.

Persons with serious mental illness (SMI) struggle with work functioning even with the assistance of vocational services. The current study sought to address this problem by examining a cognitive-behavioral therapy to augment vocational services. Fifty-two adults with SMI receiving vocational services participated in a pre-post feasibility trial of the Cognitive Behavior Therapy for Work Success (CBTw) intervention. CBTw is a 12-week manualized intervention that addresses cognitive and behavioral factors that impact work functioning. Competitive work outcomes were assessed in the 12 weeks preceding baseline and after the intervention. The results demonstrate strong session attendance and a low attrition rate. There were also significant improvements in work outcomes. Specifically, among participants unemployed at baseline, 50.0% attained work during follow-up. These findings provide preliminary evidence that CBTw may be a feasible intervention to augment vocational services; further controlled research should examine its benefit to work outcomes in people with SMI.

Metacognitive Reflection and Insight Therapy (MERIT): Application to a Long-Term Therapy Case of Borderline Personality Disorder.

Impairments in metacognitive capacity-or the processes that enable individuals to access, understand, and integrate their ideas about their own and others' mental states-are a core barrier to recovery for many people with borderline personality disorder. Although therapeutic approaches that focus on metacognitive capacity are emerging, few deal with the concept of recovery at a foundational level. This article describes how a form of metacognitively oriented psychotherapy focused on recovery, metacognitive reflection and insight therapy (MERIT), assisted a patient with borderline personality disorder and initial metacognitive deficits to develop a complex understanding of himself and others and then to use that knowledge to act as an agent in the world and effectively respond to life challenges. The eight elements of MERIT that stimulate and promote metacognitive capacity are presented with an emphasis on how they were implemented to assist the patient in achieving recovery.

Emergence of psychotic content in psychotherapy: An exploratory qualitative analysis of content, process, and therapist variables in a single case study.

OBJECTIVE: Emerging integrative metacognitive therapies for schizophrenia seek to promote subjective aspects of recovery. Beyond symptom remission, they are concerned with shared meaning-making and intersubjective processes. It is unclear, however, how such therapies should understand and respond to psychotic content that threatens meaning-making in therapeutic contexts. Accordingly, we sought to understand what factors precede and potentially trigger psychotic content within psychotherapy and what aids in resolution and return to meaning-making. METHOD: Forty-eight transcripts from a single psychotherapy case were analyzed with thematic analysis. Passages of delusional or disorganized content were identified and themes present prior to the emergence and resolution of such material were identified and coded. RESULTS: Themes that preceded the emergence of psychotic content varied across early, middle, and late phases of therapy. Material related to the patient's experience of inadequacy and potential vulnerability, therapist setting boundaries within the therapeutic relationship and making challenges appeared to trigger psychotic content, especially early in treatment. CONCLUSIONS: Psychotic content may emerge in session following identifiable antecedents which change over phases of therapy. Attending to psychotic content by assuming a non-hierarchical stance and not dismissing psychotic content may aid in maintaining intersubjectivity and support patient's movements toward recovery in integrative metacognitive therapies.

Subjective Experiences of the Benefits and Key Elements of a Cognitive Behavioral Intervention Focused on Community Work Outcomes in Persons With Mental Illness.

New research suggests that group-based cognitive behavioral therapy (CBT) may help improve employment outcomes in persons with mental illness, yet the effects and potential key elements facilitating change in such interventions are unclear. Using a mixed methods approach, this study examined the perspectives of persons with mental illness after participating in a pilot study of the "CBT for Work Success" intervention. Findings demonstrate that participants valued the intervention and perceived that it assisted them in achieving work goals. Therapeutic effects included improved self-efficacy, work motivation, enhanced sense of self as workers, and increased beliefs that work success is attainable. CBT for Work Success elements perceived to be important in facilitating work goals included cognitive restructuring, behavioral coping strategies, problem solving work barriers, meaningful reflection on oneself as a worker, and important factors associated with the group process. The authors discuss the implications of these findings and future research directions.

Comparing the Costs and Acceptability of Three Fidelity Assessment Methods for Assertive Community Treatment.

Successful implementation of evidence-based practices requires valid, yet practical fidelity monitoring. This study compared the costs and acceptability of three fidelity assessment methods: on-site, phone, and expert-scored self-report. Thirty-two randomly selected VA mental health intensive case management teams completed all fidelity assessments using a standardized scale and provided feedback on each. Personnel and travel costs across the three methods were compared for statistical differences. Both phone and expert-scored self-report methods demonstrated significantly lower costs than on-site assessments, even when excluding travel costs. However, participants preferred on-site assessments. Remote fidelity assessments hold promise in monitoring large scale program fidelity with limited resources.

How Do Patients with Chronic Pain Benefit from a Peer-Supported Pain Self-Management Intervention? A Qualitative Investigation.

OBJECTIVE: Peer support is a novel and under-studied approach to the management of chronic pain. This study's purpose was to uncover the elements of a peer-supported self-management intervention that are perceived by participants as essential to achieving positive changes. DESIGN: Qualitative, semi-structured interviews. METHODS: Veterans and veteran peer coaches who participated in a pilot study of peer support Improving Pain using Peer-Reinforced Self-Management Strategies (IMPPRESS, NCT01748227) took part in qualitative semi-structured interviews after completing the 4-month intervention. Questions were designed to facilitate understanding of how participants experienced the intervention. An immersion/crystallization approach was used to analyze data. RESULTS: All 26 peer coaches and patients who completed the intervention were interviewed. Qualitative analysis revealed three elements of IMPPRESS that peer coaches and patients believed conferred benefit: 1) making interpersonal connections; 2) providing/receiving encouragement and support; and 3) facilitating the use of pain self-management strategies. CONCLUSIONS: Peer support represents a promising approach to chronic pain management that merits further study. The current study helps to identify intervention elements perceived by participants to be important in achieving positive results. Understanding how peer support may benefit patients is essential to optimize the effectiveness of peer support interventions and increase the implementation potential of peer-supported pain self-management into clinical practice.

Metacognition moderates the relationship of disturbances in attachment with severity of borderline personality disorder among persons in treatment of substance use disorders.

OBJECTIVES: Borderline personality disorder traits have been observed to be linked with both insecure attachment styles as well as deficits in mentalizing and metacognition. Less is known, however, about how attachment style does or does not interact with deficits in mentalizing and metacognition to create, sustain, or influence levels of borderline personality disorder traits. In this study, we examined the hypothesis that metacognitive mastery, which is the ability to use knowledge about mental states of self and others to cope with distress and solve social problems, moderates the relationship of anxious attachment style with the severity of borderline personality disorder traits. METHODS: Concurrent assessments were gathered of metacognitive mastery using the Metacognitive Assessment Scale Abbreviated, anxious attachment style using the Experiences of in Close Relationships Scale, and borderline personality disorder traits using the Structured Clinical Interview for DSM-IV Axis II Disorders. Participants were 59 adults in an early phase of recovery from substance use disorders in a residential setting. RESULTS: Multiple regression revealed that metacognitive mastery moderated the relationship of anxious attachment style with the number of borderline personality disorder traits. A median split of the anxious attachment and metacognitive mastery scores was performed yielding 4 groups. An analysis of covariance revealed that participants with higher levels of anxious attachment and poorer metacognitive mastery had more borderline personality disorder traits did than the other groups after controlling for levels of psychopathology. CONCLUSION: Insecure attachment may be associated with higher number of borderline personality disorder traits in the presence of deficits in metacognitive mastery. Patients with substance use and borderline personality disorder traits may benefit from treatment which addresses metacognitive mastery.

An Integrative Psychotherapy Approach to Foster Community Engagement and Rehabilitation in Schizophrenia: A Case Study Illustration.

This case study illustrates the use of a long-term integrative psychotherapy approach with a middle- aged man with chronic schizophrenia and a mood disorder. The case of "Holst" describes a man with a history of insecure attachment and trauma who later went on to contract a serious chronic illness, precipitating the onset of psychotic symptoms, depression, and chronic suicidal ideation, resulting in multiple hospitalizations. Combining metacognition-oriented therapy with elements of cognitive behavioral therapy and psychiatric rehabilitation, this approach fostered significantly improved community functioning and attainment of personal goals over time. Through the journey of therapy, the patient also developed a more coherent narrative about his life, established a stable sense of self, and became an active agent in the world. This case illustration demonstrates that these three different approaches can be used in a sequential and complementary fashion to foster recovery in the midst of serious physical and mental illness.

Comparison of Assertive Community Treatment Fidelity Assessment Methods: Reliability and Validity.

Assertive community treatment is known for improving consumer outcomes, but is difficult to implement. On-site fidelity measurement can help ensure model adherence, but is costly in large systems. This study compared reliability and validity of three methods of fidelity assessment (on-site, phone-administered, and expert-scored self-report) using a stratified random sample of 32 mental health intensive case management teams from the Department of Veterans Affairs. Overall, phone, and to a lesser extent, expert-scored self-report fidelity assessments compared favorably to on-site methods in inter-rater reliability and concurrent validity. If used appropriately, these alternative protocols hold promise in monitoring large-scale program fidelity with limited resources.

A brief peer support intervention for veterans with chronic musculoskeletal pain: a pilot study of feasibility and effectiveness.

OBJECTIVE: The aim of this study was to pilot test a peer support intervention, involving peer delivery of pain self-management strategies, for veterans with chronic musculoskeletal pain. DESIGN: Pretest/posttest with 4-month intervention period. METHODS: Ten peer coaches were each assigned 2 patients (N = 20 patients). All had chronic musculoskeletal pain. Guided by a study manual, peer coach-patient pairs were instructed to talk biweekly for 4 months. Pain was the primary outcome and was assessed with the PEG, a three-item version of the Brief Pain Inventory, and the PROMIS Pain Interference Questionnaire. Several secondary outcomes were also assessed. To assess change in outcomes, a linear mixed model with a random effect for peer coaches was applied. RESULTS: Nine peer coaches and 17 patients completed the study. All were male veterans. Patients' pain improved at 4 months compared with baseline but did not reach statistical significance (PEG: P = 0.33, ICC [intra-class correlation] = 0.28, Cohen's d = -0.25; PROMIS: P = 0.17, d = -0.35). Of secondary outcomes, self-efficacy (P = 0.16, ICC = 0.56, d = 0.60) and pain centrality (P = 0.06, ICC = 0.32, d = -0.62) showed greatest improvement, with moderate effect sizes. CONCLUSIONS: This study suggests that peers can effectively deliver pain self-management strategies to other veterans with pain. Although this was a pilot study with a relatively short intervention period, patients improved on several outcomes.

Metacognitive Deficits in Schizophrenia: Presence and Associations With Psychosocial Outcomes.

Early formulations of schizophrenia suggested that the disorder involves a loss of ability to form integrated ideas about oneself, others, and the world, resulting in reductions in complex goal-directed behaviors. Exploring this position, the current review describes evidence that persons with schizophrenia experience decrements in their ability to form complex ideas about themselves and to ultimately use that knowledge to respond to psychological and social challenges. Studies are detailed that find greater levels of these impairments, defined as metacognitive deficits, in persons with schizophrenia in both early and later phases of illness as compared with other clinical and community groups. Furthermore, studies linking metacognitive deficits with poorer psychosocial functioning and other variables closely linked to outcomes are summarized. Clinical implications are also discussed.