Effectiveness and cost-effectiveness of online recorded recovery narratives in improving quality of life for people with non-psychotic mental health problems: a pragmatic randomized controlled trial.

Narratives describing first-hand experiences of recovery from mental health problems are widely available. Emerging evidence suggests that engaging with mental health recovery narratives can benefit people experiencing mental health problems, but no randomized controlled trial has been conducted as yet. We developed the Narrative Experiences Online (NEON) Intervention, a web application providing self-guided and recommender systems access to a collection of recorded mental health recovery narratives (n=659). We investigated whether NEON Intervention access benefited adults experiencing non-psychotic mental health problems by conducting a pragmatic parallel-group randomized trial, with usual care as control condition. The primary endpoint was quality of life at week 52 assessed by the Manchester Short Assessment (MANSA). Secondary outcomes were psychological distress, hope, self-efficacy, and meaning in life at week 52. Between March 9, 2020 and March 26, 2021, we recruited 1,023 participants from across England (the target based on power analysis was 994), of whom 827 (80.8%) identified as White British, 811 (79.3%) were female, 586 (57.3%) were employed, and 272 (26.6%) were unemployed. Their mean age was 38.4±13.6 years. Mood and/or anxiety disorders (N=626, 61.2%) and stress-related disorders (N=152, 14.9%) were the most common mental health problems. At week 52, our intention-to-treat analysis found a significant baseline-adjusted difference of 0.13 (95% CI: 0.01-0.26, p=0.041) in the MANSA score between the intervention and control groups, corresponding to a mean change of 1.56 scale points per participant, which indicates that the intervention increased quality of life. We also detected a significant baseline-adjusted difference of 0.22 (95% CI: 0.05-0.40, p=0.014) between the groups in the score on the "presence of meaning" subscale of the Meaning in Life Questionnaire, corresponding to a mean change of 1.1 scale points per participant. We found an incremental gain of 0.0142 quality-adjusted life years (QALYs) (95% credible interval: 0.0059 to 0.0226) and a £178 incremental increase in cost (95% credible interval: -£154 to £455) per participant, generating an incremental cost-effectiveness ratio of £12,526 per QALY compared with usual care. This was lower than the £20,000 per QALY threshold used by the National Health Service in England, indicating that the intervention would be a cost-effective use of health service resources. In the subgroup analysis including participants who had used specialist mental health services at baseline, the intervention both reduced cost (-£98, 95% credible interval: -£606 to £309) and improved QALYs (0.0165, 95% credible interval: 0.0057 to 0.0273) per participant as compared to usual care. We conclude that the NEON Intervention is an effective and cost-effective new intervention for people experiencing non-psychotic mental health problems.

The legacy of William (Bill) A. Anthony: Past, present and future.

William (Bill) A. Anthony was a pioneer in the field of psychosocial/psychiatric rehabilitation and recovery. He established the Center for Psychiatric Rehabilitation at Boston University and served as the editor/coeditor of the Psychosocial Rehabilitation Journal (later Psychiatric Rehabilitation Journal). He helped to clarify ideas, principles, policies, and practices that promoted the right and ability of people living with psychiatric disabilities and mental health challenges to aspire to and achieve their own vision of a meaningful life. This introductory article briefly overviews Bill's contributions to psychiatric rehabilitation and recovery of people with mental health challenges and his influence on recent work in this field, a sample of which is presented in the current special section dedicated to him. To conclude, the article overviews this special section, which reports on studies in the United States and elsewhere, addressing supported education, recovery colleges, photovoice to promote community integration, and policy developments in Israel. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Supported education for students with psychiatric disabilities: A systematic review of effectiveness studies from 2009 to 2021.

OBJECTIVE: For more than a decade, an increase in psychiatric disabilities has been reported worldwide among students in postsecondary education. Supported Education (SEd) interventions support students with psychiatric disabilities to return to or remain in education. As not much is known about the effectiveness of SEd, we conducted a systematic review of the research on the effects of SEd on educational functioning, including study success and student satisfaction. METHOD: The EBSCOhost Complete browser (e.g., ERIC, MEDLINE, PsycARTICLES, PsycINFO, SocINDEX) was used to search for peer-reviewed studies representing effectiveness data on SEd published in English or Dutch/Flemish between 2009 and 2021. The quality of the research was assessed for all studies included. RESULTS: A total number of seven studies were eligible. The results indicated a positive impact of SEd on the educational functioning (e.g., educational attainment, grade point average, comfort with the student role) of students with psychiatric disabilities. In addition, effects on time spent on educational activities, interpersonal skills, and sustained attention/vigilance were found. The quality of the studies appeared to be moderate. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: The limited available evidence suggests the added value of SEd interventions for the educational functioning of students with psychiatric disabilities. Reviewing the effectiveness of SEd was difficult due to differences in the SEd interventions used, the generally small research populations, and differing research designs. To improve the quality of research on this subject, future studies should overcome the identified shortcomings. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Building organizational readiness: initial field testing of an expert-informed typology of implementation strategies.

BACKGROUND: Organizational readiness is a known barrier to implementing evidence-based practices (EBPs) in community mental health services. A robust methodology for enhancing organizational readiness for implementation (ORI) has the potential to improve implementation outcomes of EBPs and ensure better services for people with a psychiatric disability. Prior work established a framework of implementation strategies targeting ORI enhancement by asking a group of implementation experts from various fields to categorize strategies from the "Expert Recommendations for Implementing Change" (ERIC) Project into three readiness stages, consistent with the pre-action stages of the Transtheoretical Model of behavioral change: Pre-contemplation, Contemplation, and Preparation. The current study provides initial confirmation and refinement to this expert-driven typology based on community mental health field experiences. METHODS: We conducted in-depth interviews with stakeholders involved in a recent EBP implementation project. Participants included staff (n=9) from four community mental health agencies and the implementation team who facilitated the project (n=3). Their pre-implementation experiences were compared with the experts' typology to identify consistencies and discrepancies. RESULTS: The participants' experiences were congruent with two thirds of the strategies identified by the experts for specific ORI stages. The refinements included 12 strategies used in additional stages beyond the experts' classification, four strategies from the ERIC list that were not included in the ORI typology, and five new strategies. CONCLUSIONS: This study provides initial confirmation and refinements to the previously published ORI typology. The results offer guidance as to how ORI could be enhanced in the community mental health field.

Enhancing organizational readiness for implementation: constructing a typology of readiness-development strategies using a modified Delphi process.

BACKGROUND: Knowledge about the development of organizational readiness for implementation (ORI) is limited. ORI, referred to as the willingness and capacity of all relevant stakeholders to change practice, is critical for increasing the adoption rate of evidence-based practices and improving implementation outcomes. However, no methodology currently guides ORI's enhancement or addresses differences in readiness needs across an organization. This study used the transtheoretical model (TTM) as a framework for classifying a well-established compilation of implementation strategies into three readiness stages: pre-contemplation, contemplation, and preparation. METHODS: A modified Delphi method was used to establish consensus among a panel of purposefully selected research and field implementation experts. The Delphi process involved three rounds of online questionnaires. The third round also included a live video discussion to clarify definitions in an effort to increase consensus among experts. RESULTS: Of the 73 strategies reviewed, the experts identified 75% (n = 55) as relevant for pre-implementation and reached a high-level agreement on the assignment of 7% (n = 5) of the strategies to the pre-contemplation stage (ORI-1), 25% (n = 18) to the contemplation stage (ORI-2), and 52% (n = 38) to the preparation stage (ORI-3). Several strategies were identified as relevant to more than one stage. CONCLUSIONS: Participating experts were able to reach high-level agreement on the relevance of specific sets of implementation strategies to each of the three ORI stages. The lowest number of strategies was assigned to ORI-1 and the highest number to ORI-3. Given the overlap of strategies across ORI stages, there is a need to better understand the specific utilization of such strategies at different stages. Future studies are needed to empirically evaluate the relevance and applicability of this expert-informed typology based on implementers' experiences in the field.

Recorded Mental Health Recovery Narratives as a Resource for People Affected by Mental Health Problems: Development of the Narrative Experiences Online (NEON) Intervention.

BACKGROUND: The internet enables sharing of narratives about health concerns on a substantial scale, and some digital health narratives have been integrated into digital health interventions. Narratives describing recovery from health problems are a focus of research, including those presented in recorded (eg, invariant) form. No clinical trial has been conducted on a web-based intervention providing access to a collection of Recorded Recovery Narratives (RRNs). OBJECTIVE: This study presents knowledge produced through the development of the Narrative Experiences Online (NEON) Intervention, a web-based intervention incorporating the algorithmic recommendation of RRNs. METHODS: Knowledge was gathered through knowledge integration (KI) activities. KI1 synthesized previous studies to produce the NEON Impact Model describing how accessing RRNs produces health-related outcomes. KI2 developed curation principles for the NEON Collection of RRNs through consultation with the NEON Lived Experience Advisory Panel and the curation of a preliminary collection. KI3 identified harm minimization strategies for the NEON Intervention through consultation with the NEON International Advisory Board and Lived Experience Advisory Panel. The NEON Intervention was finalized through 2 research studies (RS). In RS1, mental health service users (N=40) rated the immediate impact of randomly presented narratives to validate narrative feedback questions used to inform the recommendation algorithm. In RS2, mental health service users (n=25) were interviewed about their immediate response to a prototype of the NEON Intervention and trial procedures and then were interviewed again after 1 month of use. The usability and acceptability of the prototype and trial procedures were evaluated and refinements were made. RESULTS: KI1 produced the NEON Impact Model, which identifies moderators (recipient and context), mechanisms of connection (reflection, comparison, learning, and empathy), processes (identification of change from narrative structure or content and internalization of observed change), and outcomes (helpful and unhelpful). KI2 identified 22 curation principles, including a mission to build a large, heterogeneous collection to maximize opportunities for connection. KI3 identified seven harm minimization strategies, including content warnings, proactive and reactive blocking of narratives, and providing resources for the self-management of emotional distress. RS1 found variation in the impact of narratives on different participants, indicating that participant-level feedback on individual narratives is needed to inform a recommender system. The order of presentation did not predict narrative feedback. RS2 identified amendments to web-based trial procedures and the NEON Intervention. Participants accessed some narratives multiple times, use reduced over the 4-week period, and narrative feedback was provided for 31.8% (105/330) of narrative accesses. CONCLUSIONS: RRNs can be integrated into web-based interventions. Evaluating the NEON Intervention in a clinical trial is feasible. The mixed methods design for developing the NEON Intervention can guide its extension to other clinical populations, the design of other web-based mental health interventions, and the development of narrative-based interventions in mental health.

Ready to roll: Strategies and actions to enhance organizational readiness for implementation in community mental health.

Background: Organizational readiness for implementation (ORI) is a barrier to disseminating recovery-oriented evidence-based practices for people with severe mental illnesses. However, there is a knowledge gap regarding implementation strategies and specific actions related to those strategies that may enhance ORI across organizations. The Transtheoretical Model (TTM) is a well-established stage-based model used to support organizational change. In TTM, the first three stages-Pre-contemplation, Contemplation, and Preparation-represent the pre-implementation phase, during which ORI should be developed. This study explored ORI enhancement strategies reported as useful by different stakeholders in the field of community mental health (CMH) and tested the applicability of the TTM readiness stages as an organizing framework to direct ORI development. Methods: The study included the following two phases: (1) a qualitative exploration of ORI enhancement actions reported by various stakeholders in the CMH field (N = 16) based on their experience in successful implementation projects and (2) a consolidation process performed by the research team to create coherent groups of actions and their overarching implementation strategies per readiness stage. Results: A comprehensive list of strategies and related actions was created. The strategies and actions correspond with each of the first three stages of the TTM. Stakeholders differed in their methods of facilitating engagement across the organization and in their level of involvement in developing ORI. Conclusions: This study is a first step in conceptualizing a systematic process for developing ORI using the TTM as a theoretical framework. Future studies should test the transferability and effectiveness of this repository to other implementation efforts, expend the lists per stage, and further explore differences between stakeholders' role in ORI development. Plain language abstract: Interventions that were proven effective in supporting the recovery of people with mental illnesses are not sufficiently available in the field of community mental health. One barrier to getting those interventions implemented is the lack of willingness and preparedness of organizations to change their practice, also referred to as organizational readiness for implementation (ORI). Little is known about how to enhance ORI to increase the availability of interventions. This study explored actions used to enhance ORI by people in different roles who successfully implemented new recovery-oriented interventions in community mental health settings. The actions were organized into three stages of readiness development based on the Transtheoretical Model (TTM) of behavioral change. Differences were found between administrators, consultants, supervisors, and providers in the type and number of strategies they described. The results show the applicability of the TTM as an organizing framework for ORI development and provide sets of strategies and specific actions to support different readiness needs across the organization.

From Residential Care to Supportive Housing for People With Psychiatric Disabilities: Past, Present, and Future.

For centuries, treatment and accommodation for people with significant mental health conditions in many countries, including the United States, have been viewed as necessarily inseparable elements, first in asylums and then, with deinstitutionalization, in community care models. The advent of psychiatric rehabilitation and later, recovery, helped to shift the paradigm of mental health services and the role of housing, to one focused on promoting the ability of individuals to achieve not only a life located in the community, but one that reflects a meaningful life as part of a community. In this context, supportive housing emerged as a model based on integrated, permanent, affordable housing, selected by the person, with flexible supports that are functionally separate, but available as needed and wanted. This model of housing has been predominant in American mental health services for over 20 years, and evidence now exists for its outcomes in terms of housing stability, symptom reduction, and psychosocial variables. Current challenges, both at the societal and the individual level, confront the sustainability of supportive housing, with some efforts being made by housing groups to address these challenges. This article reviews the evolution of supportive housing and its basic tenets, identifying the challenges and some efforts to address them. In addition, the article discusses the current social and economic climate, which appears to be shaping opposing trends, and makes a call to action, to mitigate the possible risks to the future of this value-based housing approach.

Characteristics of mental health recovery narratives: Systematic review and narrative synthesis.

BACKGROUND: Narratives of recovery from mental health distress have played a central role in the establishment of the recovery paradigm within mental health policy and practice. As use of recovery narratives increases within services, it is critical to understand how they have been characterised, and what may be missing from their characterisation thus far. The aim of this review was to synthesise published typologies in order to develop a conceptual framework characterising mental health recovery narratives. METHOD: A systematic review was conducted of published literature on the characteristics of mental health recovery narratives. Narrative synthesis involved identifying characteristics and organising them into dimensions and types; and subgroup analysis based on study quality, narrator involvement in analysis, diagnosis of psychosis and experience of trauma. The synthesis was informed by consultation with a Lived Experience Advisory Panel and an academic panel. The review protocol was pre-registered (Prospero CRD42018090188). RESULTS: 8951 titles, 366 abstracts and 121 full-text articles published January 2000-July 2018 were screened, of which 45 studies analysing 629 recovery narratives were included. A conceptual framework of mental health recovery narratives was developed, comprising nine dimensions (Genre; Positioning; Emotional Tone; Relationship with Recovery; Trajectory; Use of Turning Points; Narrative Sequence; Protagonists; and Use of Metaphors), each containing between two and six types. Subgroup analysis indicated all dimensions were present across most subgroups, with Turning Points particularly evident in trauma-related studies. CONCLUSIONS: Recovery narratives are diverse and multidimensional. They may be non-linear and reject coherence. To a greater extent than illness narratives, they incorporate social, political and rights aspects. Approaches to supporting development of recovery narratives should expand rather than reduce available choices. Research into the narratives of more diverse populations is needed. The review supports trauma-informed approaches, and highlights the need to understand and support post-traumatic growth for people experiencing mental health issues.

FiRe: Evaluation of a fidelity measure to promote implementation of evidence-based rehabilitation.

OBJECTIVE: This article describes a measure developed to assess fidelity of working with the Boston University approach to Psychiatric Rehabilitation (BPR) in Dutch mental health care. The instrument is intended to measure and improve BPR adherence and clinician competence on an individual level and within individual rehabilitation processes. METHOD: Rotating pairs of 4 BPR specialists used Fidelity of Rehabilitation (FiRe) to evaluate the fidelity of BPR as applied in 114 rehabilitation processes. The content of these processes was documented by the 27 rehabilitation practitioners who delivered the approach. RESULTS: Interrater reliability (.66) was good as were correlations between the first and second assessments (.74), also increasing over time. FiRe was able to distinguish those delivering the approach at an expert level from nonexperts, expressing concurrent validity. FiRe was also related to practitioner attitude toward rehabilitation, a possibly similar construct. In this study, the average level of BPR adherence according to our fidelity model was low. During the 10.5-month review period, overall FiRe scores improved slightly, but this effect was not significant. However, practitioners reported that feedback based on FiRe helped them to enhance their skills. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: This first version of FiRe is a valid and reliable instrument with which to gain insight into the quality and fidelity of individual practitioners' rehabilitation practices. The instrument used in this study will be further developed in line with study results. More importantly, FiRe raises questions about the definition of good BPR, a topic that should be explored more extensively in future research. (PsycINFO Database Record

Establishing a Research Agenda for Understanding the Role and Impact of Mental Health Peer Specialists.

Mental health peer specialists are individuals with serious mental illnesses who receive training to use their lived experiences to help others with serious mental illnesses in clinical settings. This Open Forum discusses the state of the research for mental health peer specialists and suggests a research agenda to advance the field. Studies have suggested that peer specialists vary widely in their roles, settings, and theoretical orientations. Theories of action have been proposed, but none have been tested. Outcome studies have shown benefits of peer specialists; however, many studies have methodological shortcomings. Qualitative descriptions of peer specialists are plentiful but lack grounding in implementation science frameworks. A research agenda advancing the field could include empirically testing theoretical mechanisms of peer specialists, developing a measure of peer specialist fidelity, conducting more rigorous outcomes studies, involving peer specialists in executing the research, and assessing various factors that influence implementing peer specialist services and testing strategies that could address those factors.

Development of the REFOCUS intervention to increase mental health team support for personal recovery.

BACKGROUND: There is an emerging evidence base about best practice in supporting recovery. This is usually framed in relation to general principles, and specific pro-recovery interventions are lacking. AIMS: To develop a theoretically based and empirically defensible new pro-recovery manualised intervention--called the REFOCUS intervention. METHOD: Seven systematic and two narrative reviews were undertaken. Identified evidence gaps were addressed in three qualitative studies. The findings were synthesised to produce the REFOCUS intervention, manual and model. RESULTS: The REFOCUS intervention comprises two components: recovery-promoting relationships and working practices. Approaches to supporting relationships comprise coaching skills training for staff, developing a shared team understanding of recovery, exploring staff values, a Partnership Project with people who use the service and raising patient expectations. Working practices comprise the following: understanding values and treatment preferences; assessing strengths; and supporting goal-striving. The REFOCUS model describes the causal pathway from the REFOCUS intervention to improved recovery. CONCLUSIONS: The REFOCUS intervention is an empirically supported pro-recovery intervention for use in mental health services. It will be evaluated in a multisite cluster randomised controlled trial (ISRCTN02507940).

Competing priorities: staff perspectives on supporting recovery.

Recovery has come to mean living a life beyond mental illness, and recovery orientation is policy in many countries. The aims of this study were to investigate what staff say they do to support recovery and to identify what they perceive as barriers and facilitators associated with providing recovery-oriented support. Data collection included ten focus groups with multidisciplinary clinicians (n = 34) and team leaders (n = 31), and individual interviews with clinicians (n = 18), team leaders (n = 6) and senior managers (n = 8). The identified core category was Competing Priorities, with staff identifying conflicting system priorities that influence how recovery-oriented practice is implemented. Three sub-categories were: Health Process Priorities, Business Priorities, and Staff Role Perception. Efforts to transform services towards a recovery orientation require a whole-systems approach.

Skill building: assessing the evidence.

OBJECTIVE: Skill building for adults involves multiple approaches to address the complex problems related to serious mental illness. Individuals with schizophrenia are often the research focus. The authors outline key skill-building approaches and describe their evidence base. METHODS: Authors searched meta-analyses, research reviews, and individual studies from 1995 through March 2013. Databases surveyed were PubMed, PsycINFO, Applied Social Sciences Index and Abstracts, Sociological Abstracts, Social Services Abstracts, Published International Literature on Traumatic Stress, ERIC, and CINAHL. Authors chose from three levels of evidence (high, moderate, and low) on the basis of benchmarks for the number of studies and quality of their methodology. They also described the evidence of service effectiveness. RESULTS: Over 100 randomized controlled trials and numerous quasi-experimental studies support rating the level of evidence as high. Outcomes indicate strong effectiveness for social skills training, social cognitive training, and cognitive remediation, especially if these interventions are delivered through integrated approaches, such as Integrated Psychological Therapy. Results are somewhat mixed for life skills training (when studied alone) and cognitive-behavioral approaches. The complexities of schizophrenia and other serious mental illnesses call for individually tailored, multimodal skill-building approaches in combination with other treatments. CONCLUSIONS: Skill building should be a foundation for rehabilitation services covered by comprehensive benefit plans that attend to the need for service packages with multiple components delivered in various combinations. Further research should demonstrate more conclusively the long-term effectiveness of skill building in real-life situations, alone and in various treatment combinations. Studies of diverse subpopulations are also needed.

Uses and abuses of recovery: implementing recovery-oriented practices in mental health systems.

An understanding of recovery as a personal and subjective experience has emerged within mental health systems. This meaning of recovery now underpins mental health policy in many countries. Developing a focus on this type of recovery will involve transformation within mental health systems. Human systems do not easily transform. In this paper, we identify seven mis-uses ("abuses") of the concept of recovery: recovery is the latest model; recovery does not apply to "my" patients; services can make people recover through effective treatment; compulsory detention and treatment aid recovery; a recovery orientation means closing services; recovery is about making people independent and normal; and contributing to society happens only after the person is recovered. We then identify ten empirically-validated interventions which support recovery, by targeting key recovery processes of connectedness, hope, identity, meaning and empowerment (the CHIME framework). The ten interventions are peer support workers, advance directives, wellness recovery action planning, illness management and recovery, REFOCUS, strengths model, recovery colleges or recovery education programs, individual placement and support, supported housing, and mental health trialogues. Finally, three scientific challenges are identified: broadening cultural understandings of recovery, implementing organizational transformation, and promoting citizenship.

Should the training of clinical psychologists require competence in the treatment and rehabilitation of individuals with a serious mental illness?

The readership of Psychiatric Rehabilitation Journal is broad and not limited to a single profession; however, in this opinion piece, as the Journal moves under the umbrella of publications operated by the American Psychological Association, we focus on the need to engage one profession, clinical psychology, more fully in working with individuals with a serious mental illness. Many of the arguments provided below also have clear relevance to other professions, and may have implications for increasing their involvement in work with this population. In this opinion piece, we call attention to the insufficient training and lack of investment and involvement in the treatment of serious mental illness of one mental health profession, clinical psychology.

Psychiatric rehabilitation interventions: a review.

Psychiatric rehabilitation has become accepted by the mental health field as a legitimate field of study and practice. Over the last several decades various psychiatric rehabilitation programme models and procedures have been developed, evaluated and disseminated. At the same time the process of psychiatric rehabilitation has been specified and its underlying values and practitioner technology articulated. This review describes the psychiatric rehabilitation process and in so doing differentiates psychosocial interventions that can be classified as psychiatric rehabilitation interventions from other psychosocial interventions. Furthermore, the major psychiatric rehabilitation interventions are examined within a framework of the psychiatric rehabilitation process with a review of their evidence. The review concludes that psychiatric rehabilitation interventions are currently a mixture of evidence-based practices, promising practices and emerging methods that can be effectively tied together using the psychiatric rehabilitation process framework of helping individuals with serious mental illnesses choose, get and keep valued roles, and together with complementary treatment orientated psychosocial interventions, provide a broad strategy for facilitating recovery.