Achieving gender equity in academic psychiatry - barriers to involvement and solutions for success.

OBJECTIVE: Women face considerable barriers in pursuing careers in academic psychiatry. METHODS: A group of Australian and New Zealand academic women psychiatrists convened in September 2022 to identify and propose solutions to increase opportunities for women in academic psychiatry. RESULTS: Limiting factors were identified in pathways to academia including financial support, engagement and coordination between academia and clinical services, and flexible working conditions. Gender biases and the risk of burnout were additional and fundamental barriers. Potential solutions include offering advanced training certificates to enable trainees to commence a PhD and Fellowship contemporaneously; improved financial support; expanding opportunities for research involvement; establishing mentoring opportunities and communities of practice; and strategies to enhance safety at work and redress gender bias and imbalance in academia. CONCLUSIONS: Support for women in research careers will decrease gender disparity in academic psychiatry and may decrease problematic gender bias in research. Fellows and trainees, the RANZCP, universities, research institutes, governments, industry and health services should collaborate to develop and implement policies supporting changes in working conditions and training. Facilitating the entry and retention of women to careers in academic psychiatry requires mentoring and development of a community of practice to provide and enable support, role modelling, and inspiration.

The efficacy of exercise interventions for all types of inpatients across mental health settings: A systematic review and meta-analysis of 47 studies.

This systematic review and meta-analysis investigated the benefits, safety and adherence of exercise interventions delivered in inpatient mental health settings, quantified the number of exercise trials that provided support to maintain engagement in exercise post-discharge, and reported patient feedback towards exercise interventions. Major databases were searched from inception to 22.06.2022 for intervention studies investigating exercise in mental health inpatient settings. Study quality was assessed using Cochrane and ROBINS-1 checklists. Fifty-six papers were included from 47 trials (including 34 RCTs), bias was high. Exercise improved depression (Standardised mean difference = -0.416; 95% Confidence interval -0.787 to -0.045, N = 15) compared to non-exercise comparators amongst people with a range of mental illnesses, with further (albeit limited) evidence suggesting a role of exercise in cardiorespiratory fitness and various other physical health parameters and ameliorating psychiatric symptoms. No serious exercise-related adverse events were noted, attendance was ≥80% in most trials, and exercise was perceived as enjoyable and useful. Five trials offered patients post-discharge support to continue exercise, with varying success. In conclusion, exercise interventions may have therapeutic benefits in inpatient mental health settings. More high-quality trials are needed to determine optimal parameters, and future research should investigate systems to support patients to maintain exercise engagement once discharged.

Examining the outcomes of the first one hundred residents in a community based residential rehabilitation unit for people affected by severe and persistent mental illness.

OBJECTIVE: Community-based residential rehabilitation for people experiencing severe and persistent mental illness (SPMI) is increasingly available as an alternative to psychiatric inpatient care. Understanding who accesses these services and their outcomes will inform the optimal allocation of limited public mental health resources. METHOD: This retrospective cohort study explored the outcomes of the first 100 consumers supported by a new Australian Community Care Unit (CCU). The primary outcome focus was acute mental health service use (emergency department presentations, acute mental health inpatient admission days), and secondary outcome foci were accommodation independence and substance use. RESULTS: When the 365 days before and after CCU support were compared, significant reductions in acute mental health bed days were observed (22 days, W = 3.373, p = .001); greater reductions were noted for those staying >182 days (31 days, W = 3.373, p = .001). Additionally, significant improvements in accommodation independence were found, (W = 3.373, p = .001). CONCLUSION: CCU consumers experienced reductions in acute mental health inpatient service use and improved accommodation independence. These observations are consistent with the intended functioning of the residential rehabilitation service.

Can high-intensity interval training improve mental health outcomes in the general population and those with physical illnesses? A systematic review and meta-analysis.

OBJECTIVE: High-intensity interval training (HIIT) is a safe and feasible form of exercise. The aim of this meta-analysis was to investigate the mental health effects of HIIT, in healthy populations and those with physical illnesses, and to compare the mental health effects to non-active controls and other forms of exercise. DESIGN: Random effects meta-analyses were undertaken for randomised controlled trials (RCTs) comparing HIIT with non-active and/or active (exercise) control conditions for the following coprimary outcomes: mental well-being, symptoms of depression, anxiety and psychological stress. Positive and negative affect, distress and sleep outcomes were summarised narratively. DATA SOURCES: Medline, PsycINFO, Embase and CENTRAL databases were searched from inception to 7 July 2020. ELIGIBILITY CRITERIA FOR SELECTING STUDIES: RCTs that investigated HIIT in healthy populations and/or those with physical illnesses and reported change in mental well-being, depression, anxiety, psychological stress, positive/negative affect, distress and/or sleep quality. RESULTS: Fifty-eight RCTs were retrieved. HIIT led to moderate improvements in mental well-being (standardised mean difference (SMD): 0.418; 95% CI: 0.135 to 0.701; n=12 studies), depression severity (SMD: -0.496; 95% CI: -0.973 to -0.020; n=10) and perceived stress (SMD: -0.474; 95% CI: -0.796 to -0.152; n=4) compared with non-active controls, and small improvements in mental well-being compared with active controls (SMD:0.229; 95% CI: 0.054 to 0.403; n=12). There was a suggestion that HIIT may improve sleep and psychological distress compared with non-active controls: however, these findings were based on a small number of RCTs. CONCLUSION: These findings support the use of HIIT for mental health in the general population. LEVEL OF EVIDENCE: The quality of evidence was moderate-to-high according to the Grading of Recommendations Assessment, Development and Evaluation) criteria. PROSPERO REGISTRATION NUMBER: CRD42020182643.

A comparison study of three physical activity measurement tools examining acceptability in people with psychosis.

OBJECTIVE: To compare the acceptability of three distinct physical activity measurement tools in people with psychosis: an objective measurement tool, a self-report measure, and an exercise capacity test. METHODS: We measured the completion rate for each measurement tool. Participants rated the ease/difficulty of each measure using a 7-point Likert scale. Participants were also asked to rank the three tools in order of the ease of use. RESULTS: Sixty-six per cent (46/69) of participants completed all three assessment tools, and 60.9% (42/69) completed the acceptability questionnaire. The majority of the participants found it easy to complete all three measurement tools. The majority (52.8%) of the participants ranked the objective measurement tool as the easiest to use. CONCLUSION: All three measures were acceptable to people with psychosis, but objective measurement tools may be easier to use.

Compliance of metabolic monitoring at rehabilitation facilities.

OBJECTIVES: To examine compliance with routine metabolic monitoring at four rehabilitation facilities within the Metro South Addiction and Mental Health Services in Queensland. METHODS: A retrospective chart audit was undertaken on 63 residents of rehabilitation facilities with electronic health records from 1 October 2014 to 30 March 2015. RESULTS: Evidence of any metabolic monitoring was recorded for 87% of residents. Compliance rates differed for monitoring waist circumference (97%), blood pressure (97%), high-density lipoprotein (79%), triglycerides (81%) and plasma glucose (83%). Evidence of communication with residents and primary healthcare providers were each found in 41% of the sample. CONCLUSIONS: In current clinical practice, metabolic monitoring is high for residents of rehabilitation facilities in Queensland with serious mental illness. However, many residents do not receive adequate communication regarding their results and, disturbingly, results are not forwarded to their primary healthcare providers. This can result in people not receiving treatment for modifiable factors of metabolic syndrome.

Embedding exercise interventions as routine mental health care: implementation strategies in residential, inpatient and community settings.

OBJECTIVES: Evaluation of physical activity (PA) programs among populations with severe mental illness (SMI) has predominately focused on efficacy and therapeutic benefits. There is now strong evidence to support the benefits of PA in people with SMI. What remains is a gap in the implementation of pragmatic and sustainable PA interventions in mental-health settings. The current paper provides examples of interventions that have been successfully implemented in Australian settings, identifies key components of successful PA interventions and outlines practical strategies that can assist with widespread implementation of PA interventions in mental-health settings. CONCLUSIONS: There is an emergence of PA interventions being imbedded within a variety of mental-health settings. These interventions vary in terms of mode and intensity of service delivery. Yet, all aim to increase PA and reduce sedentary behaviour. Adopting the identified strategies may help facilitate successful implementation and increase access to PA interventions for mental-health service users.

Longitudinal comparative evaluation of the equivalence of an integrated peer-support and clinical staffing model for residential mental health rehabilitation: a mixed methods protocol incorporating multiple stakeholder perspectives.

BACKGROUND: A novel staffing model integrating peer support workers and clinical staff within a unified team is being trialled at community based residential rehabilitation units in Australia. A mixed-methods protocol for the longitudinal evaluation of the outcomes, expectations and experiences of care by consumers and staff under this staffing model in two units will be compared to one unit operating a traditional clinical staffing. The study is unique with regards to the context, the longitudinal approach and consideration of multiple stakeholder perspectives. METHODS/DESIGN: The longitudinal mixed methods design integrates a quantitative evaluation of the outcomes of care for consumers at three residential rehabilitation units with an applied qualitative research methodology. The quantitative component utilizes a prospective cohort design to explore whether equivalent outcomes are achieved through engagement at residential rehabilitation units operating integrated and clinical staffing models. Comparative data will be available from the time of admission, discharge and 12-month period post-discharge from the units. Additionally, retrospective data for the 12-month period prior to admission will be utilized to consider changes in functioning pre and post engagement with residential rehabilitation care. The primary outcome will be change in psychosocial functioning, assessed using the total score on the Health of the Nation Outcome Scales (HoNOS). Planned secondary outcomes will include changes in symptomatology, disability, recovery orientation, carer quality of life, emergency department presentations, psychiatric inpatient bed days, and psychological distress and wellbeing. Planned analyses will include: cohort description; hierarchical linear regression modelling of the predictors of change in HoNOS following CCU care; and descriptive comparisons of the costs associated with the two staffing models. The qualitative component utilizes a pragmatic approach to grounded theory, with collection of data from consumers and staff at multiple time points exploring their expectations, experiences and reflections on the care provided by these services. DISCUSSION: It is expected that the new knowledge gained through this study will guide the adaptation of these and similar services. For example, if differential outcomes are achieved for consumers under the integrated and clinical staffing models this may inform staffing guidelines.

Successful rechallenge with clozapine after treatment associated eosinophilia.

OBJECTIVE: Eosinophilia has been associated with the use of clozapine. Where clozapine associated eosinophilia develops, and is associated with organ specific damage, clozapine is usually ceased. In cases of treatment associated eosinophilia without evidence of organ specific damage, clozapine would also typically be withdrawn. There are small numbers of reports in the literature describing patients who have had a successful rechallenge of clozapine having previously stopped treatment due to eosinophilia without associated organ specific inflammation. We report the case of a man who underwent a successful retrial of clozapine. METHOD: Case from authors' clinical practice reviewed. RESULTS: We present the case of a young man with treatment resistant schizophrenia who underwent a successful re-challenge of clozapine, having previously ceased treatment due to an eosinophilia associated with treatment. CONCLUSION: We believe that the current report provides further evidence that it may be unnecessary to cease treatment in all patients who develop an eosinophilia without organ dysfunction whilst on clozapine. Furthermore, where clozapine has been ceased due to an eosinophilia without evidence of organ specific inflammation, clozapine rechallenge with increased haematological monitoring should be considered.

The effect of exercise on global, social, daily living and occupational functioning in people living with schizophrenia: A systematic review and meta-analysis.

BACKGROUND: Schizophrenia is associated with high rates of global, social and occupational functional impairments. While prior meta-analyses have extensively examined the impact of exercise on physical and mental health, the impact on functioning in schizophrenia have yet to be fully established. This review aimed to update the evidence base regarding the impact of exercise on functioning in schizophrenia, and explore moderators of effect. METHODS: A systematic search was conducted to identify randomized controlled trials (RCTs) of exercise evaluating global functioning versus any comparator in people with schizophrenia; between group meta-analyses of global functioning (and secondary - social, living skills, occupational, adverse events) were computed using a random effects model. Subgroup analyses based on diagnosis and aspects of the intervention were conducted. RESULTS: 18 full text articles were included, involving 734 participants. A moderate impact of exercise on global functioning was found (g = 0.40, 95 % C·I. = 0.12 to 0.69, p = 0.006), with a moderate impact of exercise on social (N = 5, g = 0.54 95 % C.I = 0.16 to 0.9 p = 0.005), and daily living functioning (N = 3, g = 0.65, 95 % C.I. = 0.07 to 1.22, p = 0.005). CONCLUSIONS: There is good evidence that exercise can improve the global functioning of people with schizophrenia, with preliminary evidence for social and daily living skills; exercise should be considered an important adjunct to usual care. Higher impacts on global functioning were seen in aerobic interventions and of at least moderate to vigorous intensity. More research is required into resistance training, in early psychosis cohorts and to evaluate the comparison of exercise with other established psychosocial therapies.

Changes in self-determined motivation for exercise in people with mental illness participating in a community-based exercise service in Australia.

Exercise has diverse benefits for physical and mental health in people with mental illness; however, it is unclear how to effectively promote exercise motivation in this group. The aim of this study is to evaluate the effectiveness of interventions utilising exercise instruction or behavioural counselling with people with mental illness to improve self-determined motivation for exercise, and physical and mental health. Participants were adults (aged 18+ years) receiving mental health services. Participants could choose from two 8-week programs comprising weekly group-based sessions delivered by an exercise physiologist: (a) exercise instruction in a gym (GYM) or (b) behavioural counselling (MOT). Self-determined motivation was measured using the Behaviour Regulations for Exercise Questionnaire (BREQ3). Physical health indicators included waist circumference, blood pressure, leg strength (sit-to-stand test), physical capacity (six-minute walk test) and self-reported exercise. Mental health was assessed using the Kessler-6 scale of psychological distress. Most of the 95 participants chose exercise instruction (GYM = 60; MOT = 35). At baseline, participants who chose MOT had higher external motivation, body mass index, waist circumference and psychological distress, and a higher proportion had multiple physical comorbidities than those who chose GYM. More self-determined motivation was associated with meeting physical activity guidelines. Post-intervention, GYM participants had significant improvements in self-determined motivation, psychological distress and sit-to-stand test; MOT participants had significant improvements in integrated regulation, self-reported exercise and physical functioning. In conclusion, exercise instruction can improve self-determined motivation; however, more intensive behavioural counselling support may be needed to improve self-determined motivation. Counselling programs can increase exercise behaviour and may appeal more to people with poorer health and more external motivation. Findings have high ecological validity and applicability to real-world implementation of exercise interventions. To accommodate people with diverse conditions and motivations, motivational counselling should be combined with practical exercise support, and participants afforded the autonomy to decide their level of involvement.

Biopsychology of Physical Activity in People with Schizophrenia: An Integrative Perspective on Barriers and Intervention Strategies.

People with severe mental illness such as schizophrenia experience high physical comorbidity, leading to a 15-20-year mortality gap compared with the general population. Lifestyle behaviours such as physical activity (PA) play important roles in the quest to bridge this gap. Interventions to increase PA engagement in this population have potential to be efficacious; however, their effectiveness can be hindered by low participant engagement, including low adherence and high drop-out, and by implementation of interventions that are not designed to compensate for the cognitive and motivational impairments characteristic for this group. Moreover, and importantly, the negative symptoms of schizophrenia are associated with neurobiological changes in the brain, which-based on principles of biopsychology-can contribute to poor motivation and impaired decision-making processes and behavioural maintenance. To increase PA levels in people with schizophrenia, better understanding of these neurological changes that impact PA engagement is needed. This has the potential to inform the design of interventions that, through enhancement of motivation, could effectively increase PA levels in this specific population. Incorporating strategies that address the dopamine dysregulation associated with schizophrenia, such as boosting the role of reward and self-determined motivation, may improve long-term PA maintenance, leading to habitual PA. Consideration of motivation and behavioural maintenance is also needed to impart health benefits such as prevention of chronic disease, which is associated with currently low PA levels in this high metabolic risk population. Taking a biopsychological perspective, we outline the neural pathways involved in motivation that are impacted by schizophrenia and propose strategies for promoting motivation for and PA engagement from adoption to habit formation.

High Intensity Interval training (HIIT) for people with severe mental illness: A systematic review & meta-analysis of intervention studies- considering diverse approaches for mental and physical recovery.

There is a mortality gap of 15 to 20 years for people with severe mental illness (SMI - psychotic spectrum, bipolar, major depressive disorders). Modifiable risk factors include inactivity and low cardiorespiratory fitness (CRF). Exercise can improve mental and physical outcomes; optimal type and intensity of exercise for people with SMI has yet to be determined. High Intensity Interval training (HIIT) is an exercise with distinct cardio-metabolic advantages in other disease populations compared to traditional moderate intensity continuous training (MCT). We investigated the feasibility and efficacy of HIIT for people with SMI. Major electronic databases were searched, identifying HIIT studies for adults experiencing SMI.Data on feasibility, safety, study design, sample characteristics, and physical and psychological outcomes were extracted and systematically reviewed. Meta-analyses were conducted within group, pre and post HIIT interventions, and between group, to compare HIIT with control conditions. Nine articles were identified including three pre/post studies, one non randomised and five randomised trials, (366 participants, 45.1% female). HIIT appears as feasible as MCT, with few safety concerns. Following HIIT, there was a moderate improvement in CRF and depression. There was no difference between HIIT and MCT for adherence or CRF.HIIT improved depression more than MCT.

Feasibility and Acceptability of a Student-Led Lifestyle (Diet and Exercise) Intervention Within a Residential Rehabilitation Setting for People With Severe Mental Illness, GO HEART (Group Occupation, Health, Exercise And Rehabilitation Treatment).

PURPOSE: People with severe mental illness (SMI) experience poor physical health and premature mortality, contributed significantly by modifiable lifestyle risk factors such as poor nutrition, low cardiorespiratory fitness, and physical inactivity. Lifestyle interventions can reduce cardiometabolic risk and confer a range of other positive mental and physical health benefits. We assessed the feasibility, acceptability, safety, and preliminary effectiveness of a lifestyle (combined dietary and exercise) intervention lead by senior exercise and dietetics students in a residential mental health rehabilitation setting. DESIGN: Single arm, prospective study evaluating outcomes pre and post a 10-week dietary and exercise intervention. METHOD: People with SMI from three residential rehabilitation units participated in a mixed aerobic and resistance training exercise intervention three times per week that was combined with a dietary intervention (six individual and group sessions). Primary outcome considerations were feasibility (recruitment, retention, and participation rates), acceptability, and adverse events. Secondary outcomes were preliminary effectiveness; (functional exercise capacity, volume of exercise, and metabolic markers), psychiatric symptoms, quality of life, and attitudes to exercise. RESULTS: Forty-two participants were recruited (92% primary diagnosis of schizophrenia). Intervention feasibility was supported by high levels of recruitment (68%), retention (77%), and participation (70% exercise, 65% diet sessions); and the absence of serious adverse events. Significant improvements in functional exercise capacity, volume of exercise, general psychiatric symptoms, and negative psychotic symptoms occurred. Anthropometric and metabolic blood markers did not change. While the intervention was acceptable to participants, motivation for and perceived value of exercise reduced over 10 weeks. CONCLUSIONS: A brief pragmatic student-led lifestyle intervention integrated into usual mental health care was feasible, acceptable, safe, and scalable across two additional mental health residential rehabilitation sites, and resulted in physical and mental health improvements. Increased frequency of dietary sessions and length of dietary intervention may improve metabolic outcomes in the future. People with SMI living in residential rehabilitation units should have access to lifestyle programs to address modifiable lifestyle risk factors. While this brief intervention was feasible and acceptable, this study highlights some of the challenges associated with maintaining motivation for healthy lifestyles for people with SMI. Longer term investigation of real-world lifestyle interventions is warranted, together with additional interventions that may support people with SMI to sustain motivation to address lifestyle factors. CLINICAL TRIAL REGISTRATION: The trial was registered with the Australian New Zealand Clinical Trials Registry (ANZCTR), Unique Identifier: ACTRN 12618000478213, http://www.anzctr.org.au Universal trial number (UTN)-U1111-1211-4009.

A Comprehensive Cohort Description and Statistical Grouping of Community-Based Residential Rehabilitation Service Users in Australia.

Background: Community Care Units (CCUs) are a model of community-based residential rehabilitation support available in Australia that assists people affected by severe and persistent mental illness to enhance their independent living skills and community involvement. These services have been subject to limited evaluation, and available descriptions of consumer cohorts lack relevance to the understanding of their rehabilitation needs. Method: A clinical assessment battery covering a broad range of relevant domains was completed with consumers commencing at three CCUs in Queensland, Australia, between December 2014 and December 2017 (N = 145). The cohort was described based on demographic, diagnostic, treatment-related variables, and the assessment battery. The comparability of included sites was assessed. This contemporary cohort was also compared to the pooled cohort of Australian community-based residential rehabilitation services emerging from a previous systematic review. Additionally, cluster analysis (CA) was completed in two stages based on the clinician-rated assessments: hierarchical CA (Wards method) to identify the optimal number of clusters, followed by K-means clustering. Results: Dominant features of the cohort were male sex and the primary diagnoses of schizophrenia spectrum disorders. The average consumer age was 31.4 years. Most consumers were referred from the community, had been living with family, and were not subject to involuntary treatment orders. No site-based differences were observed on demographic, diagnostic and treatment-related variables. However, some site-based variation in levels of symptoms and functional impairment emerged. Overall, the cohort was comparable with the Transitional Residential Rehabilitation (TRR) cohort defined in a previous systematic review. Through CA, a three-cluster solution emerged: Cluster 1 (15%) was characterised by higher levels of substance use comorbidity; Cluster 2 (39%) was characterised by higher levels of disability and symptoms; and Cluster 3 (46%) was distinguished by lower levels of general psychiatric symptoms. Conclusions: The cohort was generally comparable to the TRR cohort. Site-based variability in the characteristics of admitted consumers was minimal. The CA solution suggested that three different sub-groups of consumers are admitted to CCUs, which have implications for adapting the approach to rehabilitation. Recommendations include ensuring early availability of interventions to address co-morbidities and pacing rehabilitation expectations to consumers stage of recovery.

Evaluating the Feasibility of a Pilot Exercise Intervention Implemented Within a Residential Rehabilitation Unit for People With Severe Mental Illness: GO HEART: (Group Occupational Health Exercise and Rehabilitation Treatment).

Purpose: People with severe mental illness are sedentary, have high cardio-metabolic risks and significantly reduced life expectancy. Despite considerable data regarding positive physical and mental health outcomes following exercise interventions, implementation and evaluation of real-world programs is lacking. The primary aim of this study was to assess the feasibility of an exercise intervention implemented by exercise physiology (EP) students within a residential rehabilitation unit for residents with severe mental illness, together with assessment of a range of secondary physical and mental health outcomes pre- and post- the intervention. Design: Single arm, prospective pilot study evaluating outcomes pre- and post- a 10 week intervention. Method: Inactive people with severe mental illness participated in a mixed aerobic and resistance exercise intervention, three times per week for 10 weeks. Data was obtained from a sample of 16 residents with severe mental illness; primary diagnosis schizophrenia (n = 12). Primary outcomes were feasibility as assessed using recruitment, retention and participation rates, as well as reasons for withdrawal and amount of exercise achieved. Secondary outcomes included: functional exercise capacity was measured by the 6-min walk test; metabolic data obtained from anthropometric measurements; blood pressure; fasting cholesterol and blood sugar levels; and physical activity levels and mental health as assessed by self- administered questionnaires measured before and after the intervention. Results: Broad level acceptance of the program: high recruitment (81%), retention (77%), and participation (78%) rates were observed. Promising improvements in functional exercise capacity, volume of exercise, and negative symptoms was demonstrated in those who completed. Conclusions: Exercise interventions delivered by EP students in a residential rehabilitation setting for people with SMI are feasible; group setting, supervision and choice for engagement are important considerations. Evaluation of longitudinal, multi site studies, with the addition of dietary interventions within residential rehabilitation units are warranted. Addressing cost feasibility and cost effectiveness of such programs is recommended. The trial was registered with the Australian New Zealand Clinical Trials Registry (ANZCTR) number, Unique Identifier: ACTRN 12618000478213, http://www.anzctr.org.au Universal trial number (UTN) - U1111-1211-4009.

Reality of working in a community-based, recovery-oriented mental health rehabilitation unit: A pragmatic grounded theory analysis.

In the present study, we explored the experiences of staff working at a recovery-oriented, community-based residential mental health rehabilitation unit in Brisbane, Australia, called a 'community care unit' (CCU). A pragmatic approach to grounded theory was taken in the analysis of the transcripts of semistructured interviews with eight staff. Convenience sampling was used, and there was representation of junior and senior staff across nursing, allied health, and non-clinical support roles. Four key themes emerged from the analysis: (i) rehabilitation is different to treatment; (ii) the CCU is a positive transitional space; (iii) they (consumers) have to be ready to engage; and (iv) recovery is central to rehabilitation practice. Staff understandings of recovery in rehabilitation work were complex and included consideration of both personal and clinical recovery concepts. Rehabilitation readiness was considered important to the ability to deliver recovery-oriented care; however, the shared role of staff in maintaining engagement was acknowledged. Threats to recovery-oriented rehabilitation practice included staff burnout and external pressure to accept consumers who are not ready. The reality of working at a community-based recovery-oriented rehabilitation unit is complex. Active vigilance is needed to maintain a focus on recovery and rehabilitation. Leadership needs to focus on reducing burnout and in adapting these services to emergent needs.