Introduction to the special section on racial disparities in psychiatric rehabilitation services.

Although racial disparities in psychiatric rehabilitation services are not new, the urgency of systematic approaches to address them has gained increased attention. In particular, the current social and political climate has spotlighted historically persistent and universally prevalent problems in equitable care. This special section, consisting of six studies and a Letter to the Editor, reveals the operation and impact of structural racism and highlights the need for race-conscious practice and research in psychiatric rehabilitation. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Structural Racism, Workforce Diversity, and Mental Health Disparities: A Critical Review.

OBJECTIVE: Racial workforce diversity has been suggested as a critical pathway to address persistent racial mental health disparities. However, structural racism has been noted to diminish such workforce diversity efforts. The purpose of this critical review is to identify the mechanisms through which structural racism operates in organizations, including mental health organizations, to undermine workforce diversity efforts and reinforce inequities. METHODS: Using the theories of racialized organizations, the current review critically draws on literature underscoring the racial character of organizations as mezzo-level racialized structures that may systematically activate and uphold white privilege in the mental health workplace. RESULTS: Findings suggest that in the context of institutionalized white dominance, workers of color within mental health organizations may experience race-based cultural exclusion, identity threat, and racialized workplace emotional expression, and be burdened by racialized tasks. The workers of color may also become the means for organizations to attract communities of color due to their diverse characteristics, yet workers' effects to address disparities in mental health are minimized due to potential racialized organizational forces, including the whiteness of organizational leadership and color-blindness. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: Structural racism may create resistance to the efforts and effects of a racially diverse workforce within mental health organizations. This review calls for a race-conscious framework that drastically shifts the traditional organizational structure to an inverted hierarchy (i.e., client-centered management) to maximize diversity efforts in the mental health organizational workforce to address racial disparities in mental health.

Assessing the Recovery Assessment Scale Across Time.

OBJECTIVE: The Recovery Assessment Scale (RAS) is one of the most used recovery measures in recovery-oriented practice evaluation of people with mental health conditions. Although its psychometric properties have been extensively studied, one critical piece of information that is missing from the literature is evidence of its longitudinal factorial invariance-that is, whether the RAS measures the same recovery construct across time. The authors empirically tested the longitudinal factorial invariance assumption for the RAS. METHODS: Structural equation modeling was used to test the longitudinal factorial invariance of the RAS with data longitudinally obtained at three time points from 167 people with severe mental illness. RESULTS: The longitudinal factorial invariance assumption was supported (i.e., configural, metric, partial scalar, factor variance and covariance invariance). CONCLUSIONS: This study found empirical evidence that the RAS can measure the same recovery construct over time and thus meets one of the important prerequisites for longitudinal assessment.

Mediational paths from supervisor support to turnover intention and actual turnover among community mental health providers.

OBJECTIVE: Turnover is a critical problem for community mental health providers, and supervisors may play an important role in mitigating turnover. The current study examined the potential impact of supervisory support on turnover intention and actual turnover among community mental health providers. METHOD: We conducted path analyses with data collected longitudinally from 186 direct clinical care providers at two community mental health centers. RESULTS: Increased supervisory support was associated with lower turnover intention 6 months later, as well as reduced actual turnover 12 months later. Type of supervisory support mattered: supervisors' emotional support was most strongly associated with reduced turnover intention and turnover. However, client goal alignment support (supporting providers to help consumers achieve their goals) was directly associated with increased turnover. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: The current study suggests an important role for direct supervisors to attend to care providers' emotional support needs, which may reduce turnover intention and actual turnover. Differential supervisory support functions might impact turnover in unique ways; thus, examining more detailed change mechanisms would facilitate our understanding of factors that may prevent future turnover. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Study protocol for a controlled trial of Strengths Model Case Management in mental health services in Hong Kong.

INTRODUCTION: Although strengths-based models are popular within recovery-oriented approaches, there is still a lack of conclusive research to guide how they should be implemented. A recent meta-analysis confirmed the lack of clarity in how this perspective is operationalised and that fidelity monitoring during the implementation process is lacking. Hence, there is a clear need to evaluate the feasibility of delivering and evaluating a clearly operationalised strengths-based intervention that incorporates fidelity checks to inform more definitive research. This protocol therefore describes a controlled trial of Strengths Model Case Management (SMCM), a complex intervention, for people with severe mental illnesses in Hong Kong. This trial follows the guidelines of the Medical Research Council as a phase 2 trial. Hence, it is a pilot study that tests the feasibility and effectiveness of the model. METHODS AND ANALYSIS: This is a 9-month controlled trial that uses the Kansas Model. Participants and a matched control group are recruited on a voluntary basis, after screening for eligibility. Effectiveness of the SMCM will be measured through outcome measures taken at baseline, the mid-point and at the end of the trial. Outcomes for service users include personal recovery, hope, subjective well-being, psychiatric symptoms, perceived level of recovery features within the organisation, therapeutic alliance and achievement of recovery goals. Outcomes for care workers will include job burnout, organisational features of recovery and perceived supervisory support. With a 2×3 analysis of variance design and a moderate intervention effect (Cohen's d=0.50), a total of 86 participants will be needed for a statistical power of 0.80. ETHICS AND DISSEMINATION: Ethical approval has been obtained from the Human Research Ethics Committee for Non-Clinical Faculties at The University of Hong Kong (HRECNCF: EA140913). TRIAL REGISTRATION NUMBER: Australian New Zealand Clinical Trial Registry (ACTRN)12613001120763.

Core domains of shared decision-making during psychiatric visits: scientific and preference-based discussions.

Shared decision-making (SDM) is imperative to person-centered care, yet little is known about what aspects of SDM are targeted during psychiatric visits. This secondary data analysis (191 psychiatric visits with 11 providers, coded with a validated SDM coding system) revealed two factors (scientific and preference-based discussions) underlying SDM communication. Preference-based discussion occurred less. Both provider and consumer initiation of SDM elements and decision complexity were associated with greater discussions in both factors, but were more strongly associated with scientific discussion. Longer visit length correlated with only scientific discussion. Providers' understanding of core domains could facilitate engaging consumers in SDM.

Consumer and relationship factors associated with shared decision making in mental health consultations.

OBJECTIVE: This study explored the association between shared decision making and consumers' illness management skills and consumer-provider relationships. METHODS: Medication management appointments for 79 consumers were audio recorded. Independent coders rated overall shared decision making, minimum level of shared decision making, and consumer-provider agreement for 63 clients whose visit included a treatment decision. Mental health diagnoses, medication adherence, patient activation, illness management, working alliance, and length of consumer-provider relationships were also assessed. Correlation analyses were used to determine relationships among measures. RESULTS: Overall shared decision making was not associated with any variables. Minimum levels of shared decision making were associated with higher scores on the bond subscale of the Working Alliance Inventory, indicating a higher degree of liking and trust, and with better medication adherence. Agreement was associated with shorter consumer-provider relationships. CONCLUSIONS: Consumer-provider relationships and shared decision making might have a more nuanced association than originally thought.

Why are you here again? Concordance between consumers and providers about the primary concern in recurring psychiatric visits.

Patient-centered care has become increasingly important over the last decade, both in physical and mental health care. In support of patient-centered care, providers need to understand consumers׳ primary concerns during treatment visits. The current study explored what primary concerns were brought to recurring psychiatric visits for a sample of adults with severe mental illness (N=164), whether these concerns were concordant with those recognized by providers, and which factors predicted concordance. We identified 17 types of primary concerns, most commonly medications and symptoms, with only 50% of visits showing evidence of at least partial agreement between consumers and providers. Contrary to expectations, consumer demographics, activation, trust, and perceptions of patient-centeredness were not predictive, while greater preferences for autonomy predicted poorer agreement. Our findings highlight the need for interventions to promote a shared understanding of primary concerns in recurring psychiatric visits. Further attention is needed to ensure the provision of patient-centered care such that consumer concerns are acknowledged and addressed within recurring psychiatric visits.

The perceptions of supervisory support scale.

The implementation of recovery-oriented and evidence-based practices has become a major challenge for mental health systems and front-line practitioners. This study developed an instrument that would assess the benefits or results that accrue from supervision, including client-centered supervision. The Perceptions of Supervisory Support Scale was administered to 262 case managers. Analyses (including factor analyses and repeated measures analysis of variance) confirmed content validity and reliability. Sub-scales included: (1) emotional support; (2) support for client goal achievement; and (3) professional development support. The scale could guide support for front-line practitioners in delivering client-centered care and could be useful for future research.

Effect of Wellness Recovery Action Plan (WRAP) participation on psychiatric symptoms, sense of hope, and recovery.

OBJECTIVE: Self-management of psychiatric illness is a central tenet of consumer-directed mental health treatment. While several manualized self-management programs have been developed in recent years, the most widely disseminated is the Wellness Recovery Action Plan (WRAP). This study examined the effects of WRAP participation on psychiatric symptoms, hope, and recovery outcomes for people with severe and persistent mental illness. METHODS: A quasi-experimental study, with an experimental (n=58) and a comparison (n=56) group was conducted. WRAP sessions (8-12 week) were facilitated by one staff person and one peer worker at five community mental health centers in a Midwestern state. The Modified Colorado Symptom Index, the State Hope Scale, and the Recovery Markers Questionnaire (RMQ) were employed at the first and last WRAP sessions, as well as six months following the intervention. Repeated measures analysis of covariance and planned comparisons before and after the intervention were conducted. RESULTS: Findings revealed statistically significant group intervention effects for symptoms and hope, but not for RMQ. Planned comparisons showed statistically significant improvements for the experimental group in psychiatric symptoms and hope after the intervention, while non-significant changes occurred in the comparison group. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: The study results offer promising evidence that WRAP participation has a positive effect on psychiatric symptoms and feelings of hopefulness. If recovery is the guiding vision for mental health system reform, the study results provide evidence that WRAP programming may warrant a place in the current array of services offered through the publicly funded mental health system.

The repeated appeal to return home in older adults with dementia: developing a model for practice.

Dementia care has been trapped in a "trial and error" type of practice due to difficulty understanding the needs of older adults with severe dementia. Behavioral and Psychological Signs and Symptoms of Dementia (BPSD) can be quite difficult for residential staff. However, some experienced care workers succeed in establishing effective relationships. The goal of this study was to: 1) develop a process to identify needs behind BPSD; 2) find solutions using a team approach; and 3) apply the results to educate new workers. The KJ method was employed to reach decision-making about best practices in residential dementia care. This qualitative method is used to organize group data collected in the field and is based on understanding complex situations. A group process of 12 Japanese care workers experienced in understanding and responding to the "repeated appeal to return home" of residents in nursing care facilities is highlighted along with an illustrative case example. The workgroup met over two years. The study revealed five steps in understanding the needs behind the appeal, which include: (1) Listen to the voice and go with the flow of the behavior; (2) Learn about the inner experience; (3) Learn about the contextual environment of "here and now" situations; (4) Reflect on the care environment; and (5) Find the keyword. This needs identification process has application to other cultural contexts. The implications of this study for practitioners who work with people with dementia in residential settings will be discussed.