Using a stakeholder-engaged, iterative, and systematic approach to adapting collaborative decision skills training for implementation in VA psychosocial rehabilitation and recovery centers.

BACKGROUND: Adaptation of interventions is inevitable during translation to new populations or settings. Systematic approach to adaptation can ensure that fidelity to core functions of the intervention are preserved while optimizing implementation feasibility and effectiveness for the local context. In this study, we used an iterative, mixed methods, and stakeholder-engaged process to systematically adapt Collaborative Decision Skills Training for Veterans with psychosis currently participating in VA Psychosocial Rehabilitation and Recovery Centers. METHODS: A modified approach to Intervention Mapping (IM-Adapt) guided the adaptation process. An Adaptation Resource Team of five Veterans, two VA clinicians, and four researchers was formed. The Adaptation Resource Team engaged in an iterative process of identifying and completing adaptations including individual qualitative interviews, group meetings, and post-meeting surveys. Qualitative interviews were analyzed using rapid matrix analysis. We used the modified, RE-AIM enriched expanded Framework for Reporting Adaptations and Modifications to Evidence-based interventions (FRAME) to document adaptations. Additional constructs included adaptation size and scope; implementation of planned adaptation (yes-no); rationale for non-implementation; and tailoring of adaptation for a specific population (e.g., Veterans). RESULTS: Rapid matrix analysis of individual qualitative interviews resulted in 510 qualitative codes. Veterans and clinicians reported that the intervention was a generally good fit for VA Psychosocial Rehabilitation and Recovery Centers and for Veterans. Following group meetings to reach adaptation consensus, 158 adaptations were completed. Most commonly, adaptations added or extended a component; were small in size and scope; intended to improve the effectiveness of the intervention, and based on experience as a patient or working with patients. Few adaptations were targeted towards a specific group, including Veterans. Veteran and clinician stakeholders reported that these adaptations were important and would benefit Veterans, and that they felt heard and understood during the adaptation process. CONCLUSIONS: A stakeholder-engaged, iterative, and mixed methods approach was successful for adapting Collaborative Decision Skills Training for immediate clinical application to Veterans in a psychosocial rehabilitation center. The ongoing interactions among multiple stakeholders resulted in high quality, tailored adaptations which are likely to be generalizable to other populations or settings. We recommend the use of this stakeholder-engaged, iterative approach to guide adaptations.

Psychosocial and functional contributors to personal recovery in serious mental illness.

Background: Although recovery-oriented services have been conceptualized to improve personal recovery, related research often focuses on measures of clinical recovery. Identifying the relationships between personal recovery, clinical recovery, and psychosocial variables will inform service components and outcome measurement in recovery-oriented services. Aims: This study sought to determine the connection between personal recovery and two sets of potential contributors: psychosocial variables (i.e., empowerment, resilience, and consumer involvement) and functional indicators of clinical recovery. Method: These relationships were examined by analyzing survey data collected from 266 consumers who are receiving public mental health services in the United States. Results: Empowerment, resilience and psychological involvement were associated with personal recovery. Clinical recovery did not uniquely contribute to personal recovery once psychosocial factors were accounted for. Interactions revealed that the relationship between psychological involvement and personal recovery was stronger for those who had been recently hospitalized, and for those with relatively greater resilience. Conclusions: Results indicate that personal recovery is an essential outcome measure for recovery-oriented services that cannot be replaced by clinical recovery outcome measurement. Additionally, empowerment, resilience, and consumer involvement are key components of recovery, which suggests that services and outcome measures should prioritize incorporation of these constructs.

Provider-Associated Measurement Error in Routine Outcome Monitoring in Community Mental Health.

Despite the strengths of routine outcome monitoring (ROM) in community mental health settings, there are a number of barriers to effective implementation of ROM, including measurement error due to provider factors (e.g., training level) and non-target client factors (i.e., client characteristics which have no meaningful relationship to the outcome of interest). In this study, ROM data from 80 client-provider dyads were examined for sources of variance due to provider factors and non-target client factors. Results indicated that provider factors and non-target client factors accounted for between 9.6 and 54% of the variance in the ROM measures. Our findings supported past research that provider characteristics impact ROM, and added the novel finding that client gender, age, diagnosis, and cognition also impact ROM. Methods to increase accuracy and utility of ROM in community mental health are discussed.

Enhancing patient-clinician collaboration during treatment decision-making: study protocol for a community-engaged, mixed method hybrid type 1 trial of collaborative decision skills training (CDST) for veterans with psychosis.

BACKGROUND: Patient participation in treatment decision making is a pillar of recovery-oriented care and is associated with improvements in empowerment and well-being. Although demand for increased involvement in treatment decision-making is high among veterans with serious mental illness, rates of involvement are low. Collaborative decision skills training (CDST) is a recovery-oriented, skills-based intervention designed to support meaningful patient participation in treatment decision making. An open trial among veterans with psychosis supported CDST's feasibility and demonstrated preliminary indications of effectiveness. A randomized control trial (RCT) is needed to test CDST's effectiveness in comparison with an active control and further evaluate implementation feasibility. METHODS: The planned RCT is a hybrid type 1 trial, which will use mixed methods to systematically evaluate the effectiveness and implementation feasibility of CDST among veterans participating in a VA Psychosocial Rehabilitation and Recovery Center (PRRC) in Southern California. The first aim is to assess the effectiveness of CDST in comparison with the active control via the primary outcome, collaborative decision-making behavior during usual care appointments between veterans and their VA mental health clinicians, and secondary outcomes (i.e., treatment engagement, satisfaction, and outcome). The second aim is to characterize the implementation feasibility of CDST within the VA PRRC using the Practical Robust Implementation and Sustainability Model framework, including barriers and facilitators within the PRRC context to support future implementation. DISCUSSION: If CDST is found to be effective and feasible, implementation determinants gathered throughout the study can be used to ensure sustained and successful implementation at this PRRC and other PRRCs and similar settings nationally. TRIAL REGISTRATION: ClinicalTrials.gov NCT04324944. Registered on March 27, 2020. Trial registration data can be found in Appendix 1.

Longitudinal relationships between neurocognition, theory of mind, and community functioning in outpatients with serious mental illness.

The purpose of this study was to examine relationships between neurocognition, theory of mind, and community functioning in a sample of 43 outpatients with serious mental illness (SMI). Relationships between baseline values and changes over time were analyzed using multilevel modeling. The results showed that a) neurocognition and theory of mind were each associated with community functioning at baseline, b) community functioning improved during approximately 12 months of treatment, c) greater improvement in neurocognition over time predicted higher rates of improvement in community functioning, d) theory of mind did not predict change in community functioning after controlling for neurocognition, and e) the effect of change in neurocognition on community functioning did not depend on the effect of baseline neurocognition. This study provides empirical support that individuals with SMI may experience improvement in community functioning, especially when they also experience improvement in neurocognition. Limitations and recommendations for future research are discussed.

Olmstead's implementation: Differences in enforcement approaches.

Olmstead v. L.C. ex rel Zimring (1999) was a landmark U.S. Supreme Court decision holding that unjustified segregation of people with disabilities is impermissible discrimination; specifically, if the clinician and client believe community integration to be appropriate, the state must have reasonable accommodations in place for the client to be in the community. Enforcement of the Olmstead decision for people with serious mental illness (SMI) has taken many shapes, from the U.S. Department of Justice's (DOJ) settlement agreements requiring substantive development of community mental health services and aggressive community integration protocols, to the Third Circuit approach which requires only lower census numbers in the state psychiatric hospital (SPH). The question of whether Olmstead is being differentially enforced is addressed in an empirical, qualitative analysis of legal documents, including court opinions and settlement agreements. Through legal research spanning all U.S. jurisdictions, five distinct Olmstead enforcement approaches in ten different states were identified. The enforcement approaches are described, and limitations and future directions are discussed. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Domains of Vulnerability, Resilience, Health Habits, and Mental and Physical Health for Health Disparities Research.

Health disparities associated with severe mental illness (SMI) have become a major public health concern. The disparities are not directly due to the SMI. They involve the same leading causes of premature death as in the general population. The causes of the disparities are therefore suspected to reflect differences in health-related behavior and resilience. As with other problems associated with SMI, studying non-clinical populations at risk for future onset provides important clues about pathways, from vulnerability to unhealthy behavior and compromised resilience, to poor health and reduced quality of life. The purpose of this study was to identify possible pathways in a sample of public university students. Four domains of biosystemic functioning with a priori relevance to SMI-related vulnerability and health disparities were identified. Measures reflecting various well-studied constructs within each domain were factor-analyzed to identify common sources of variance within the domains. Relationships between factors in adjacent domains were identified with linear multiple regression. The results reveal strong relationships between common factors across domains that are consistent with pathways from vulnerability to health disparities, to reduced quality of life. Although the results do not provide dispositive evidence of causal pathways, they serve as a guide for further, larger-scale, longitudinal studies to identify causal processes and the pathways they follow to health consequences.

Social cognition moderates the influence of child physical abuse on inpatient psychiatric rehabilitation.

Moderating effects of social cognition in the relationship between the severity of history of child physical abuse (CPA) and social functioning were examined using 12-month longitudinal data among 143 participants with severe mental illness (SMI) in an inpatient psychiatric rehabilitation program. The adverse effects of the severity of history of CPA on social functioning were compensated for by greater social inference and lower external locus of control. Specifically, despite the severity of history of CPA, individuals with intact or greater social inference showed greater social functioning than did those with lower social inference. The decrease in externality, regardless of the history of CPA, seemed to be therapeutic for individuals with SMI. Considering the heterogeneity in both SMI and CPA, the current finding sheds light on providing trauma-informed, individualized treatment and assessment planning for individuals with SMI and a history of CPA.

Ideal and real treatment planning processes for people with serious mental illness in public mental health care.

Treatment planning processes are a fundamental component of evidence-based practice in mental health for people with serious mental illness (SMI), who often present with complex concerns and require an interdisciplinary treatment team. It is unclear how well treatment planning practices in usual care settings for SMI adhere to best practices guidelines. In this study, we used qualitative methods to increase understanding of typical treatment planning practices. Twelve mental health providers completed a participatory dialogue focused on discussing perceptions of ideal and real treatment planning processes. Content analysis of the transcription from the dialogue was used to identify major themes and subthemes. Analysis revealed 6 primary themes with 23 subthemes. Providers described the ideal treatment planning process as dynamic and collaborative, including thorough assessment and inclusion of all stakeholders including the consumer, providers, and family members. Real treatment planning was described as directed by institutional and regulatory needs, resulting in treatment plans that were not personalized and not communicated to frontline staff or the consumer. These results indicate that providers have a strong understanding of evidence-based principles of treatment decision-making. However, actual treatment planning processes rarely live up to those principles. Providers identified several obstacles to enacting best practices. Although many obstacles were system-level, providers themselves also contributed to the gap between ideal and real treatment planning. Additional training and education may help to close this gap. Consumer self-advocacy is also important, given that providers often see themselves as lacking agency to make changes. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Skills-based intervention to enhance collaborative decision-making: systematic adaptation and open trial protocol for veterans with psychosis.

BACKGROUND: Collaborative decision-making is an innovative decision-making approach that assigns equal power and responsibility to patients and providers. Most veterans with serious mental illnesses like schizophrenia want a greater role in treatment decisions, but there are no interventions targeted for this population. A skills-based intervention is promising because it is well-aligned with the recovery model, uses similar mechanisms as other evidence-based interventions in this population, and generalizes across decisional contexts while empowering veterans to decide when to initiate collaborative decision-making. Collaborative Decision Skills Training (CDST) was developed in a civilian serious mental illness sample and may fill this gap but needs to undergo a systematic adaptation process to ensure fit for veterans. METHODS: In aim 1, the IM Adapt systematic process will be used to adapt CDST for veterans with serious mental illness. Veterans and Veteran's Affairs (VA) staff will join an Adaptation Resource Team and complete qualitative interviews to identify how elements of CDST or service delivery may need to be adapted to optimize its effectiveness or viability for veterans and the VA context. During aim 2, an open trial will be conducted with veterans in a VA Psychosocial Rehabilitation and Recovery Center (PRRC) to assess additional adaptations, feasibility, and initial evidence of effectiveness. DISCUSSION: This study will be the first to evaluate a collaborative decision-making intervention among veterans with serious mental illness. It will also contribute to the field's understanding of perceptions of collaborative decision-making among veterans with serious mental illness and VA clinicians, and result in a service delivery manual that may be used to understand adaptation needs generally in VA PRRCs. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT04324944.

Stress, trauma, racial/ethnic group membership, and HPA function: Utility of hair cortisol.

Discrimination, poverty, and other aspects of the minority experience produce stress associated with health disparities. The hypothalamic-pituitary-adrenal (HPA) axis, a neuroendocrine subsystem usually monitored through assay of the hormone cortisol, is thought to play a key role in this relationship. Cortisol assay using hair specimens is a technology that promises to address important methodological problems in large-scale studies of health, well-being, and racial/ethnic status. The purpose of this study is to evaluate the potential of a hair cortisol assay-based method for studying trait-like HPA response to low to moderate levels of stress, associated with racial/ethnic discrimination and related social processes, among well-functioning young adults. The hair cortisol measure was shown to be highly reliable; it detected differences in gender and ethnic/racial identity and was correlated with a history of physical abuse and measures of experienced microaggression. The results support the promise of hair-based cortisol assay as a key methodology in health disparities research. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

The effects of a staff-training program in behavior management and social-learning principles on staff-patient interactions within a psychiatric rehabilitation inpatient unit.

Despite the existence of effective behavioral interventions for people diagnosed with serious mental illness (SMI), these continue to be underutilized. Barriers to implementation include a low frequency of staff-patient interactions, as well as a lack of knowledge about, and negative attitudes toward, behavioral interventions. Therefore, we examined the effects of a mandatory behavioral staff-training program on staff-patient interactions on a long-term psychiatric inpatient program for individuals with SMI. Staff-training consisted of two-phases: didactic training followed by a written exam, and in vivo training and assessment. From pre- to posttraining, all staff demonstrated increased positive and therapeutic behaviors and decreased negative behaviors when interacting with patients. Additionally, at baseline, nonmedical staff (psychologists, social workers) displayed significantly more therapeutic and fewer negative behaviors compared with medical staff (psychiatrists, nurses, mental health workers), and this pattern persisted at posttraining despite improvements in both groups. Importantly, completion of the staff-training program was associated with improvements in patient behavior. Although both written and in vivo test scores significantly predicted change in negative staff behaviors toward patients, the in vivo test performance increased predictive ability over and above that of written test performance. Staff who disagreed with behavioral management principles displayed less improvement in negative behaviors from pre- to postassessment. These data have implications for clarifying staff training needs in programs for chronically ill people with SMI. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Collaborative decision skills training: Feasibility and preliminary outcomes of a novel intervention.

Increasing consumer empowerment and agency in treatment decision-making is a priority for improving recovery among people with serious mental illness (SMI), as it is associated with a number of positive outcomes, including improved treatment engagement and satisfaction. Although there are many tools to promote initiation of shared decision-making by providers, there are few tools empowering consumers to independently initiate collaborative decision-making (CDM). Therefore, this study tests the feasibility of a novel skills training intervention for outpatients with SMI, collaborative decision skills training (CDST). Twenty-one consumers with SMI currently receiving community-based day services participated in CDST. Four areas of feasibility were assessed-acceptability, demand, practicality, and preliminary evidence of efficacy. Feasibility results were favorable, including high acceptability and practicality. Demand results were mixed: rates of attendance were high and attrition was low, but participants did not complete homework as often as expected. Finally, there was evidence CDST has a positive impact on targeted outcomes; participants reported an increased sense of personal recovery, and displayed improvements in both knowledge and skills targeted by CDST. CDST is feasible to implement with fidelity and is received well by participants. Next steps include larger controlled trials of CDST, which will better inform efficacy and implementation related questions. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

Attention shaping: a reward-based learning method to enhance skills training outcomes in schizophrenia.

Disturbances in sustained attention commonly interfere with the ability of persons with schizophrenia to benefit from evidence-based psychosocial treatments. Cognitive remediation interventions have thus far demonstrated minimal effects on attention, as have medications. There is thus a gap between the existence of effective psychosocial treatments and patients' ability to effectively engage in and benefit from them. We report on the results of a multisite study of attention shaping (AS), a behavioral intervention for improving attentiveness and learning of social skills among highly distractible schizophrenia patients. Patients with chronic schizophrenia who were refractory to skills training were assigned to receive either the UCLA Basic Conversation Skills Module (BCSM) augmented with AS (n = 47) or in the standard format (n = 35). AS, a reward-based learning procedure, was employed to facilitate patients' meeting clearly defined and individualized attentiveness and participation goals during each session of a social skills training group. Primary outcome measures were observational ratings of attentiveness in each session and pre- and post-BCSM ratings of social skill and symptoms. Patients receiving social skills training augmented with AS demonstrated significantly more attentiveness in group sessions and higher levels of skill acquisition; moreover, significant relationships were found between changes in attentiveness and amount of skills acquired. Changes in attentiveness were unrelated to level or change in antipsychotic medication dose. AS is an effective example of supported cognition, in that cognitive abilities are improved within the environmental context where the patient is experiencing difficulty, leading to gains in both attention and functional outcome.

Memory as a moderator in the relationship between child sexual abuse and maladaptive functioning in people with severe mental illness.

Despite substantial research literature supporting the impact of child sexual abuse (CSA) on neuropsychological development and functional outcomes, severity of CSA has been neglected in the outcome analyses in people with severe mental illness. Furthermore, there is a paucity of studies examining variables that may moderate the relationship between CSA severity and functional outcomes. The purpose of the present study was to examine the influence of CSA severity on maladaptive functioning (e.g., irritability and psychoticism) in people with severe mental illness, and to explore the moderating effect of memory on the relationship between CSA and maladaptive functioning. Among 33 inpatients with severe mental illness, severity of CSA was positively associated with maladaptive functioning as measured by the Nurses' Observation Scale for Inpatient Evaluation-30. Persons with higher memory capacity, even among those exposed to severe CSA, were less likely to display irritability and psychoticism in an in-patient psychiatric rehabilitation program. Implications for treatment and assessment in severe mental illness are discussed.

Exploring electrophysiological correlates of social cognition in subclinical schizotypy.

Impairments in social cognition and associated abnormalities in brain function are well documented in psychotic disorders. They may represent neurodevelopmental vulnerabilities and may therefore be present in less severe or even subclinical conditions of the schizophrenia spectrum, such as schizotypy. Schizotypy has features highly suggestive of social cognitive impairments, but little is known about possible related abnormalities of brain function. This exploratory pilot study examines electrophysiological event-related potentials (ERPs) implicated in schizophrenia, in 23 undergraduates with a range of subclinical schizotypal characteristics. ERPs were recorded in response to emotional face stimuli in an experimental paradigm designed to assess very early stages of social stimulus processing. Three ERPs were assessed, P100, N170 and P300. P100 and P300 were found to be related to multiple schizotypal features, but N170 was not. The results support occurrence of social cognitive impairments linked to abnormal brain function across the schizophrenia spectrum. Copyright © 2018 John Wiley & Sons, Ltd.

Heterogeneity in recovery of psychosocial functioning during psychiatric rehabilitation: an exploratory study using latent growth mixture modeling.

Research in schizophrenia and related severe mental illness (SMI) suggests that psychiatric rehabilitation facilitates recovery of psychosocial functioning although there is considerable heterogeneity in outcomes. The present study used growth mixture modeling (GMM), a longitudinal latent variable modeling strategy, to identify classes of psychosocial functioning recovery trajectories. Archival clinical assessment data representing the first 18 months of an inpatient psychiatric rehabilitation program were analyzed from a sample of participants with schizophrenia spectrum disorders (N=162). Based on a GMM analysis of monthly Nurse Observation Scale for Inpatient Evaluation (NOSIE) scores two classes were identified that differed in overall level of psychosocial functioning, rate and nonlinear shape of change. The identified lower functioning group was characterized by poorer neurocognitive functioning at admission, a history of negative symptoms, more previous inpatient psychiatric days, and a longer length of stay in the rehabilitation program. However, this group showed significantly greater positive change in the NOSIE domains directly targeted by behavioral treatment: daily schedule competence, neatness, and irritability. Methodological and theoretical implications of these modeling strategies are discussed in the context of understanding the rehabilitation process.

Identifying mechanisms of treatment effects and recovery in rehabilitation of schizophrenia: longitudinal analytic methods.

The longitudinal dimension of schizophrenia and related severe mental illness is a key component of theoretical models of recovery. However, empirical longitudinal investigations have been underrepresented in the psychopathology of schizophrenia. Similarly, traditional approaches to longitudinal analysis of psychopathological data have had serious limitations. The utilization of modern longitudinal methods is necessary to capture the complexity of biopsychosocial models of treatment and recovery in schizophrenia. The present paper summarizes empirical data from traditional longitudinal research investigating recovery in symptoms, neurocognition, and social functioning. Studies conducted under treatment as usual conditions are compared to psychosocial intervention studies and potential treatment mechanisms of psychosocial interventions are discussed. Investigations of rehabilitation for schizophrenia using the longitudinal analytic strategies of growth curve and time series analysis are demonstrated. The respective advantages and disadvantages of these modern methods are highlighted. Their potential use for future research of treatment effects and recovery in schizophrenia is also discussed.

Beyond shared decision-making: Collaboration in the age of recovery from serious mental illness.

The role that people with serious mental illness (SMI) play in making decisions about their own treatment and rehabilitation is attracting increasing attention and scrutiny. This attention is embedded in a broader social/consumer movement, the recovery movement, whose agenda includes extensive reform of the mental health system and advancing respect for the dignity and autonomy of people with SMI. Shared decision-making (SDM) is an approach for enhancing consumer participation in health-care decision-making. SDM translates straightforwardly to specific clinical procedures that systematically identify domains of decision-making and guide the practitioner and consumer through making the decisions. In addition, Collaborative decision-making (CDM) is a set of guiding principles that avoids the connotations and limitations of SDM. CDM looks broadly at the range of decisions to be made in mental health care, and assigns consumers and providers equal responsibility and power in the decision-making process. It recognizes the diverse history, knowledge base, and values of each consumer by assuming patients can lead and contribute to decision-making, contributing both value-based information and technical information. This article further discusses the importance of CDM for people with SMI. (PsycINFO Database Record

Schizotypal personality questionnaire--brief revised (updated): An update of norms, factor structure, and item content in a large non-clinical young adult sample.

This study updates and provides evidence for the dimensionality, reliability, and validity of a standard instrument for detection and measurement of schizotypy in non-clinical young adults. Schizotypy represents a set of traits on which both nonclinical and schizophrenia-spectrum populations vary meaningfully. These traits are linked to biological, cognitive, and social dimensions of serious mental illness (SMI), to clinical and subclinical variation in personal and social functioning, and to risk for SMI. Reliable and valid identification of schizotypal traits has important implications for clinical practice and research. Four consecutive independent samples of undergraduates were administered the SPQ-BR (N=2552). Confirmatory factor analyses suggested a minor item wording change improved reliability, and this Updated questionnaire was implemented for three-quarters of the sample (SPQ-BRU). A, single-order, nine-factor structure had acceptable psychometric properties. The best fitting second-order structure included four higher-order factors that distinguished Social Anxiety and Interpersonal factors. This differentiation was supported by differential relationships with treatment history. The Disorganized factor had the greatest unique relationship with personal and family treatment history. With few exceptions, factor loadings showed stability across samples. Overall, the higher-order and lower-order factors of schizotypy demonstrated reliability and convergent and discriminant validity; detailed psychometric data are presented in a supplement.