The concept of recovery as an organizing principle for integrating mental health and addiction services

"We are a rehabilitation unit, at least on paper" - Competing representations of recovery-oriented rehabilitation in dual diagnosis treatment policy and practice

Within dual diagnosis treatment, principles of recovery are increasingly acknowledged. Nevertheless, recovery-oriented rehabilitation often becomes an abstract concept, leaving professionals in various dilemmas. This article examines competing representations of recovery-oriented rehabilitation across Danish dual diagnosis treatment policy and practice from a post-structural, analytical perspective inspired by governmentality and problematization studies. The empirical foundation consists of a qualitative ethnographic study including conducting and examining 12 national policies relevant to contemporary Danish dual diagnosis treatment practice and 23 interviews with health/welfare professionals employed at a Danish in-patient, dual diagnosis rehabilitation unit. The analysis points to a complexity between three sets of competing representations reflected in 1) the conceptual relationship between rehabilitation and recovery, 2) perceptions of knowledge based on experience or evidence, and 3) ideals of optimization and emancipation. Finally, the article discusses convergences between the competing and, at times, conflictual ideals, attempting to explain the conceptual fluffiness, discrepancies, and dilemmas experienced by professionals in dual diagnosis treatment within broader epistemological and ideological debates in social sciences and humanities.

Building on Recovery: Embracing Community Inclusion in Mental Health Policies and Services

Recovery is real and has had a transformative impact on mental health policies and services, including shifting the focus from chronicity and symptom management to the realization that individuals with mental health issues can lead meaningful lives. However, recovery has been defined, described, understood, and measured in a wide variety of ways that may account for misuses and abuses in its application and possible stagnation in its impact. It is argued that the mental health field must now build upon the strong foundations of recovery by integrating a well-established rights-oriented framework. While recovery emphasizes personal growth and hope, a rights-based perspective underscores inherent dignity, autonomy, and opportunities for acceptance and embrace in engaging in valued social roles. The addition of a rights-based framework - community inclusion, to conversations involving recovery, is aligned with the origins of recovery and how it is commonly understood, and also connects the mental health field to the dramatic positive impacts that have emerged from the longstanding centrality of this concept in the broader disability community.

How Does Individual Psychotherapy Promote Recovery for Persons with Psychosis? A Systematic Review of Qualitative Studies to Understand the Patient's Experience

Psychotherapy for individuals with psychosis is an effective treatment that promotes recovery in various ways. While there is strong quantitative evidence across modalities, less is known from the patient's perspective. There are many varied forms of psychotherapy, and gaining the patient's perspective can improve understanding of salient elements of psychotherapy and increase engagement, ultimately improving recovery rates. The purpose of this review is to identify and integrate data from published studies of patient perspectives of psychotherapy for psychosis to understand essential elements across approaches, differences between approaches, and how psychotherapy impacts recovery. We aimed to understand further: what are the perceptions about individual psychotherapy from the perspective of individuals with psychosis? The current study was a systematic review using PRISMA guidelines of studies that included qualitative interviews with persons with experiences of psychosis who participated in psychotherapy. All three authors participated in the literature search using Pubmed, APA PsycInfo, and Psychiatry Online. We identified N = 33 studies. Studies included cognitive therapies, acceptance and mindfulness approaches, trauma therapies, metacognitive therapy, and music therapy. All studies reported participants' perceived benefit with the therapeutic relationship as especially salient. Participants described diverse aspects of objective (e.g., symptoms, functioning) and subjective (e.g., self-experience or quality of life) recovery improvements, with perceived mechanisms of change, and with music therapy having some unique benefits. Participants also reported challenges and suggestions for improvement. Study findings highlight the salient aspects of psychotherapy identified by patients that may help therapists to individualize and improve approaches to psychotherapy when working with individuals experiencing psychosis. Overall, findings support the potential for integrative psychotherapy approaches for maximal treatment personalization.

Multiple psychological senses of community and community influences on personal recovery processes from substance use problems in later life: a collaborative and deductive reflexive thematic analysis

PURPOSE

There is a pressing need for substance use services to know more about how to promote recovery from substance use problems, particularly in later life. Psychological sense of community (PSOC) is an important recovery dimension. This study aims to clarify in what ways PSOC and communities influence later life recovery processes.

METHOD

A collaborative and deductive reflexive thematic approach was used to analyse 23 interviews with older adults in recovery from different substance use problems.

RESULTS

The findings suggest that PSOC and recovery in later life include multiple communities (relational, geographical, substance use-related, ideal and service-related) and affective states (PSOC and NPSOC). Older adults' recovery, moreover, can be described as personal and heterogenic (with respect to community relationships, individual needs, type of substance use problem, age of onset and meaningful activities).

CONCLUSIONS

The findings confirm age of onset, type of substance use problem and community memberships as essential to later life recovery. They also supplement prior evidence on community resources and challenges to later life recovery. Importantly, the new findings extend and nuance current understandings of later life recovery. Taken together, the article illustrates MPSOC as a useful concept, with central practical and theoretical implications for later life recovery.

MOSAIC, an example of comprehensive and integrated social and health care: care and practices oriented towards personal recovery

Background

The Mosaic project is a socio-health integration model that promotes the personal recovery of people with severe mental illness in a territory of Central Catalonia: the Bages region. The recovery approach in mental health care promotes meaningful activities and social inclusion for people with mental health disorders. The aim of this study is to examine the relationship between the level of meaningful activities and other factors associated with the mental health recovery model.

Methods

A cross-sectional design was used. Participants (n = 59) signed an informed consent and completed the following standardized instruments: Engagement in Meaningful Activities Survey; The Connor-Davidson Resilience Scale; Hert Hope Scale; and Recovery Assessment Scale.

Results

A Pearson correlation test was performed between the level of meaningful activities and life satisfaction, resilience, hope, and recovery. These data indicate that the amount of meaningful activities are strongly associated with variables related to the personal recovery process from mental health problems.

Conclusions

The integration process of MOSAIC confirms the need to accompany the recovery processes through significant occupations.

Understanding the Process of Drug Addiction Recovery Through First-Hand Experiences: A Qualitative Study in the Netherlands Using Lifeline Interviews

Understandings of drug addiction recovery are still being debated. Research on perspectives from first-hand experiences with recovery is rare and often contains short-term experiences in the context of a treatment setting. We aim to gain further understanding of recovery by analyzing autobiographical data from persons in different stages of drug addiction recovery who are not linked to any specific treatment service. We conducted 30 in-depth qualitative interviews with participants from various parts of the Netherlands. Participants self-identified as being "in recovery" or "recovered" from drug addiction for at least 3 months. Men and women are equally represented, and the sample consists of an equal number of participants in early (<1 year, n = 10), sustained (1-5 years, n = 10), and stable (>5 years, n = 10) recovery. We undertook a data-driven thematic analysis. Participants described that recovery is a broad process of change because addiction is interwoven with everything (theme 1); that recovery is reconsidering identity, seeing things in a new light (theme 2); that recovery is a staged long-term process (theme 3); and that universal life processes are part of recovery (theme 4). Thus, Drug addiction recovery is experienced as an interwoven long-term process, including identity change and common or universal life processes. Policy and clinical practice should therefore be aimed at supporting long-term tailored recovery goals and disseminating first-hand recovery experiences to enhance long-term outcomes and reduce stigmatization.

Personal recovery among people with opioid use disorder during treatment with extended-release naltrexone

Background and aims

Recovery from substance use disorders (SUD) has traditionally been equated with abstinence. "Personal recovery" however emphasizes recovery as a unique and personal process, supported by changes in connectedness, hope, identity, meaning and empowerment. This study aimed to examine personal recovery in people receiving extended-release naltrexone (XR-NTX); specifically investigate changes in personal recovery during treatment, identify groups of participants following distinct trajectories of recovery, and characteristics predicting group-belonging.

Methods

Overall change in recovery (Questionnaire about the Process of Recovery, QPR) score was assessed by linear mixed model in a subsample of 135 people with opioid use disorder (OUD) participating in a 24 + 28-week trial of XR-NTX. Growth mixture model was used to identify potential groups of people following distinct trajectories of personal recovery.

Results

Overall, there was a significant change in QPR score during treatment. Four groups with distinct recovery trajectories were identified: "initially low- increase" (G1), "initially average- no change" (G2), "initially high- no change" (G3) and "initially high- increase" (G4). The groups were different with regards to level of psychological distress, social support, and the use of benzodiazepines. In addition, previous participation in opioid agonist treatment programs, current pain, life satisfaction, employment, heroin craving and previous use of heroin also differed between groups.

Conclusions

Personal recovery among people receiving XR-NTX follows different trajectories, and various factors are associated with personal recovery. Particular attention regarding psychological distress, social support and heroin use among patients commencing XR-NTX treatment is important to facilitate successful recovery trajectories.

How, when, and to what degree do people with alcohol dependence recover their psychological wellbeing and quality of life? The Madrid Recovery Project

Introduction

The consensus on recovery from alcohol use disorder (AUD) has shifted toward encompassing psychological wellbeing and quality of life dimensions. However, few studies have explored the long-term recovery process and its dimensions, timing, styles, and modes. The aim of this study was to investigate the extent, timing, and process of psychological wellbeing and quality of life recovery in alcohol use disorder (AUD) patients, as well as the relationship with classic dimensions of AUD recovery.

Method

A cross-sectional study has been carried out with 348 participants with AUD, in different abstinence periods (1 month-28 years), and 171 control subjects. Participants underwent a psychological evaluation, which included self-informed measures of psychological wellbeing, quality of life, negative emotionality, and coping strategies related to alcohol consumption avoidance. Statistical analysis included linear and non-linear regression models between psychological dimensions and maintenance of abstinence, as well as matching the scores of the sample with AUD to those of controls. Scatter plots were used to explore inflection points. In addition, mean comparison tests were performed between participants with AUD and controls and by gender.

Results

In general, according to the regression models, there were pronounced increases in indices of wellbeing and coping strategies (and pronounced decreases in negative emotionality) during the first 5 years of abstinence, followed by less pronounced improvements. The matching of AUD subjects in wellbeing and negative emotionality indices with controls occurs at different times: (a) 1 year or less: physical health; (b) 1-4 years: psychological health; (c) 4-10 years: social relationships, wellbeing, and negative emotionality; and (d) more than 10 years: autonomy and self-acceptance. There are statistically significant differences by gender for the negative emotionality and physical health variables.

Conclusion

Recovery from AUD is a long process that involves improvements in wellbeing and quality of life. Four stages can be described in this process, with the most pronounced changes occurring during the first 5 years of abstinence. However, AUD patients take more time to obtain similar scores to controls in several psychological dimensions.

Service integration: The perspective of Australian alcohol and other drug (AOD) nurses

The recently released Victorian Mental Health Royal Commission report has recommended a shift to integrated treatment, defined as treatment for alcohol and substance use disorders and mental ill health occurring in parallel, rather than distinct systems catering to each need. However, little work has sought to determine the perceptions of nurses working in alcohol and other drug (AOD) treatment towards integrating with mental health services. In this study, we explore the perspectives of specialist AOD nurses towards the integration of mental health and AOD treatment services. Secondary analysis of semi-structured interviews with Australian specialist AOD nurses (n = 46) conducted as part of a wider workforce study in 2019. Data were analysed using thematic analysis and reported using the COREQ guidelines. Of the interviews analysed, six were AOD nurses working in an Australian state that had recently undergone service integration; however, many participants expressed perceptions of service integration. Two key themes are reported in this paper: (i) perceptions of service integration, where AOD nurses participating in our study were concerned that integration would result in the model of care they worked under being replaced by a mental health-based model that was felt to be highly risk averse, and (ii) experiences of service integration. Concerns about the focus of care as well as the complexity of care differing between the two services demonstrated a contrast in both philosophical approaches to work with consumers and legislative difference in voluntary versus compulsory care provision.

Addiction and Recovery in Dutch Governmental and Practice-Level Drug Policy: What’s the Problem Represented to be?

Around 2009, ‘recovery’ was introduced in the Netherlands as a new approach to drug addiction and addiction services. Recovery is now featured in practice-level policy but is absent in governmental drug policy. To investigate whether the Dutch recovery vision is coherent with governmental drug policy, we apply Bacchi’s What’s the problem represented to be? approach to analyse problematizations of ‘drug addiction’. We analysed two influential practice-level policy documents and one governmental drug policy document. We found that governmental policy addresses the harms and public nuisance of drug addiction, whilst practice-level policy addresses the wellbeing of persons with addiction. Despite these different starting points, the Dutch recovery vision seems coherent with both problematizations. Its adoption in the Netherlands was less subject to political debate compared to other countries. This may be a result of recovery being driven by bottom-up efforts without government intervention, leading to constructive ambiguity between government- and practice-level policies.

Centrality and Decentration: A Model for Understanding Disturbances in the Relationship of the Self to the World in Psychosis

ABSTRACT

A considerable body of phenomenological research has described different ways in which the relationship of the person to the world in psychosis is affected. This literature, however, has lacked an accepted unifying theoretical model and means of quantitatively measuring these disturbances. To address this, the current article seeks to integrate a novel phenomenological model of psychosis offered by Henri Grivois, which is explicitly concerned with centrality or a person's sense of being the center of all things, with empirical research on the integrative model of metacognition, which allows for measurements of decentration or the degree to which persons can form integrated ideas about their place in their larger community. It is proposed that this literature may allow for a model of how psychotherapy can address centrality through the building of intersubjectivity and enhancing metacognition.

'It's Really About Wellbeing': a Canadian Investigation of Harm Reduction as a Bridge Between Mental Health and Addiction Recovery

Recovery is a key concept driving system transformation in both the addiction and mental health sectors, with shared roots in advocacy and a shared focus on hope in the face of stigma, self-determination and meaningful lives. Nevertheless, while mental health recovery is possible even with on-going symptoms, addiction recovery generally starts with or leads to abstinence. This disconnection undermines coherence at the policy level and exacerbates fragmentation between services and supports in the mental health and addiction sectors in Canada and internationally. At the same time, harm reduction, which does not require abstinence, has been gaining ground in the Canadian addiction sector. This qualitative policy study explores the potential for harm reduction to bridge the gap between mental health recovery and addiction recovery in the Canadian context, drawing on diverse experiences from the mental health and addiction sectors. The findings could be adapted  internationally to address similar policy challenges.

Sensitivity and specificity of self-reported psychiatric diagnoses amongst patients treated for opioid use disorder

BACKGROUND

Patients with opioid use disorder (OUD) frequently present with comorbid psychiatric illnesses which have significant implications for their treatment outcomes. Notably, these are often identified by self-report. Our study examined the sensitivity and specificity of self-reported psychiatric diagnoses against a structured diagnostic interview in a cohort of patients receiving outpatient pharmacological treatment for OUD.

METHODS

Using cross-sectional data from adults receiving outpatient opioid agonist treatment for OUD in clinics across Ontario, Canada, we compared participants' self-reported psychiatric diagnoses with those identified by the Mini Neuropsychiatric Interview (MINI) Version 6.0 administered at the time of study entry. Sensitivity and specificity were calculated for self-report of psychiatric diagnoses.

RESULTS

Amongst a sample of 683 participants, 24% (n = 162) reported having a comorbid psychiatric disorder. Only 104 of these 162 individuals (64%) reporting a comorbidity met criteria for a psychiatric disorder as per the MINI; meanwhile, 304 (75%) participants who self-reported no psychiatric comorbidity were in fact identified to meet MINI criteria for a psychiatric disorder. The sensitivity and specificity for any self-reported psychiatric diagnoses were 25.5% (95% CI 21.3, 30.0) and 78.9% (95% CI 73.6, 83.6), respectively.

CONCLUSIONS

Our findings raise questions about the utility of self-reported psychiatric comorbidity in patients with OUD, particularly in the context of low sensitivity of self-reported diagnoses. Several factors may contribute to this including remittance and relapse of some psychiatric illnesses, underdiagnosis, and the challenge of differentiating psychiatric and substance-induced disorders. These findings highlight that other methods should be considered in order to identify comorbid psychiatric disorders in patients with OUD.

Recovery-oriented intersectoral care between mental health hospitals and community mental health services: An integrative review

BACKGROUND

Recovery-oriented intersectoral care is described as an aim in mental healthcare to create a holistic framework for planning that provides integration of treatment and rehabilitation. Existing studies show that nurses and other professionals do not take responsibility for the collaborative element of intersectoral care between mental health hospitals and community mental health services. The users of mental healthcare do not experience their patient journey as a cohesive process when they are discharged from a mental health hospital to community mental health services.

AIM

The integrative review aims to examine the professionals' experience with recovery-oriented intersectoral care between mental health hospitals and community mental health services.

DESIGN

Since the aim was to review user experience, we chose an integrative review as an obvious choice for design.

ETHICAL APPROVAL

Not applicable.

FINDINGS

Seven studies met the inclusion criteria. The interactive inductive and deductive analysis generated four themes, which clarify the experience of professionals with recovery-oriented intersectoral care between the mental health hospitals and community mental health services, namely 'structurally routine care', 'unequal balance of power between the sectors', 'bureaucracy as a barrier to recovery-oriented intersectoral care' and 'flexible mental healthcare approaches'.

CONCLUSION

This review achieves specific knowledge of recovery-oriented intersectoral care. The studies included show that recovery-oriented intersectoral care is not clearly defined. It is challenging to transfer intersectoral care to an organisation with different structural and linguistic barriers.

Multivariable modelling of factors associated with criminal convictions among people experiencing homelessness and serious mental illness: a multi-year study

People experiencing homelessness and serious mental illness exhibit high rates of criminal justice system involvement. Researchers have debated the causes of such involvement among people experiencing serious mental illness, including what services to prioritize. Some, for example, have emphasized mental illness while others have emphasized poverty. We examined factors associated with criminal convictions among people experiencing homelessness and serious mental illness recruited to the Vancouver At Home study. Participants were recruited between October 2009 and June 2011. Comprehensive administrative data were examined over the five-year period preceding study baseline to identify risk and protective factors associated with criminal convictions among participants (n = 425). Eight variables were independently associated with criminal convictions, some of which included drug dependence (RR = 1.53; P = 0.009), psychiatric hospitalization (RR = 1.44; P = 0.030), an irregular frequency of social assistance payments (compared to regular payments; 1.75; P < 0.001), and prior conviction (RR = 3.56; P < 0.001). Collectively, findings of the present study implicate poverty, social marginalization, crises involving mental illness, and the need for long-term recovery-oriented services that address these conditions to reduce criminal convictions among people experiencing homelessness and serious mental illness.

Recovery-Oriented Systems of Care: A Perspective on the Past, Present, and Future

This paper provides a perspective on the recent concept of recovery-oriented systems of care with respect to its origins in the past and its status in the present, prior to considering directions in which such systems might move in the future. Although influential in practice, this concept has yet to be evaluated empirically and has not been the object of a review. Recovery-oriented systems of care emerged from the efforts of persons with mental health and/or substance use disorders who advocated for services to go beyond the reduction of symptoms and substance use to promote a life in the community. Subsequent efforts were made to delineate the nature and principles of such services and those required of a system of such care. Coincident with the U.S. Substance Abuse and Mental Health Services Administration dropping reference to behavioral health in its revised definition of recovery, confusions and limitations began to emerge. Recovery appeared to refer more to a process of self-actualization for which an individual is responsible than to a process of healing from the effects of a behavioral health condition and associated stigma. In response, some systems are aiming to address social determinants of behavioral health conditions that transcend the scope of the individual and to develop a citizenship-oriented approach to promote community inclusion.

Music Activities and Mental Health Recovery: Service Users' Perspectives Presented in the CHIME Framework

Internationally, mental health service developments are increasingly informed by the principles of recovery, and the availability of arts and creative activities are becoming more common as part of provision. Mental health service users' experiences, reflecting on the complex nature of using music participation in recovery are, however, limited. This essay considers literature that explores how music can support mental health service users in a recovery process. We have selected studies that include a broad spectrum of music activities, as well as literature considering various concepts about recovery. The conceptual recovery framework CHIME, that includes five important components in the recovery process, is used as the backdrop for exploring music activities as a contribution to recovery-oriented practice and services in mental health care. Eleven key components are identified in which music can support the recovery process: Feelings of equality; Social and emotional wellbeing; Tolerance; Hope and social agency; Triggering encounters; Redefining and reframing; A social practice; Moments of flow and peak experiences; Moments of meaning; Continuity; and Potentials instead of limitations. This essay concludes that the experiential knowledge of music activities from service users' perspectives is essential knowledge when developing and using music activities in mental health recovery services. While this essay acknowledges that music activities can also produce unintended negative outcomes, the focus is on the positive contributions of music to mental health recovery processes.

The Healthcare Triple Aim in the Recovery Era

Recovery is the guiding vision of mental health systems and policy. However, skepticism has emerged about whether the paradigm can achieve its sought goals. We argue that embedding recovery within a quality improvement framework, such as the Triple Aim, would increase leverage for systems change and advance recovery practice. The Triple Aim's goals of improving healthcare outcomes, quality, and costs are pertinent to mental health systems, although action is also needed to address the social determinants of health. Accordingly, we propose the recovery-oriented Triple Aim, which could be used to guide policy development and evaluation of mental health services.

PTSD / substance use disorder comorbidity: Treatment options and public health needs

Purpose of Review

Posttraumatic stress disorder (PTSD) commonly co-occurs with substance use disorder (SUD) and is challenging to treat. We review all behavioral therapy models with at least one randomized controlled trial in a current PTSD/SUD population. We identify factors in selecting a model for clinical use, emphasizing a public health framework that balances the need for evidence with the need for feasibility in frontline settings.

Recent Findings

Seven published models and 6 unpublished models are reviewed. Public health considerations for choosing a model include: whether it's been studied across a broad range of SUDs and in complex SUD patients; whether it can be conducted in group modality; its appeal to patients and providers; its cost; workforce requirements; and its ability to reduce substance use in addition to PTSD.

Summary

There are two broad types of models: those that originated in the PTSD field versus the SUD field. Overall, the latter are stronger on public health factors and more feasible in SUD settings. Published models in this category include Relapse Prevention, BRENDA, and Seeking Safety. PTSD/SUD research is at an early stage and there is a need for methodology that quantifies "level of burden" (patients' socioeconomic disadvantages) across trials.

Recovery-oriented social work practice in mental health and addictions: a scoping review protocol

INTRODUCTION

Social work is a key profession in the field of mental health worldwide and the profession has values that are aligned with a recovery paradigm. However, there are gaps in understanding how social workers are applying the recovery paradigm in practice. This study will scope and synthesise the literature related to recovery and social work practice in mental health and addictions. There will also be an exploration of best practices and gaps in recovery-oriented social work practice.

METHODS AND ANALYSIS

Using a scoping review framework developed by Arksey and O'Malley, we will conduct our search in five academic databases: PsycINFO, Medline, CINAHL Plus, Sociological Abstracts and Social Services Abstracts. Articles meeting inclusion criteria will be charted to extract relevant themes and analysed using a qualitative thematic analysis approach.

ETHICS AND DISSEMINATION

This review will provide relevant information about best practices and gaps in recovery-oriented social work practice in mental health and addictions. The study will inform the development of mental health curricula in social work programmes and clinical settings. Results will be disseminated through a peer-reviewed journal and at conferences focusing on mental health, addictions, and social work education. Ethics approval is not required for this scoping review.

Recovery processes among young adults treated for alcohol and other drug problems: A five-year follow-up

Aim

Studies on recovery from alcohol and other drugs (AOD) among young adults are scarce. In the present study, young adults, previously interviewed with a focus on their recovery process shortly after they completed treatment, were re-interviewed five years later focusing on their recovery process during the last five years in relation to their former AOD problems, other problems and processes of change.

Methods

Twenty-one young adults were interviewed: 16 women and five men aged between 25 and 33 years. After transcribing the interviews, the material was analysed thematically.

Results

Three overall themes emerged: previous problems, mental illness and the search for identity. The results were discussed in relation to recovery capital, primarily focusing on human and social capital. The results indicate that the group in focus often needs professional support for mental health issues in order to reach a stable recovery.

Conclusions

Since the problems described were heterogeneous, this client group might benefit from individual treatment and extended support after treatment. Further, the results indicate that the established period of five years for a stable recovery might need to be extended for young adults.

Pathways to Recovery among Homeless People with Mental Illness: Is Impulsiveness Getting in the Way?

OBJECTIVE

This study investigates the association between impulsiveness and six dimensions of recovery among homeless people with mental illness.

METHOD

The sample was composed of 418 participants of a randomized controlled trial of Housing First, a recovery-oriented program that provides immediate access to permanent housing. The reliable change index method was used to provide an estimate of the statistical and clinical significance of the change from baseline to 24 months (i.e., clinically meaningful improvement), on outcomes that pertain to recovery dimensions: psychiatric symptoms (clinical), physical health and substance use problems (physical), residential stability (functional), arrests (criminological), community integration (social), and hope and personal confidence (existential). We tested for the effect of impulsiveness, assessed with the Barratt Impulsiveness Scale-11, on clinically meaningful improvement on each specific outcome, adjusting for age, gender and intervention assignment, as both intervention arms were included in the analysis.

RESULTS

For every increase in total impulsiveness score by one standard deviation, the odds of experiencing clinically meaningful improvement decreased by 29% (OR = 0.71, 95% CI, 0.55 to 0.91) on the clinical dimension and by 53% (OR = 0.47, 95% CI, 0.32 to 0.68) on the existential dimension. However, changes in outcomes pertaining to physical, functional, criminological, and social dimensions were not significantly influenced by impulsiveness.

CONCLUSIONS

Findings highlight the importance of addressing impulsiveness in the context of recovery-oriented interventions for homeless people with mental illness. Further research may be required to improve interventions that are responsive to unique needs of impulsive individuals to support clinical and existential recovery.

Recovery, quality of life and issues in supported housing among residents with co-occurring problems: a cross-sectional study

Purpose

Recovery for residents who experience co-occurring problems and live in supported housing takes place in everyday contexts. This study aims to explore residents’ self-reported recovery and quality of life and examine the relationships between these factors and issues in supported housing.

Design/methodology/approach

A cross-sectional study was conducted at 21 supported housing sites in six cities across Norway. A total of 104 residents (76 men and 28 women) responded to measures of recovery (Recovery Assessment Scale – Revised), life satisfaction (Manchester Short Assessment of Quality of Life), affect (single items), staff support (Brief INSPIRE) and sense of home (single items).

Findings

Linear regression analyses indicated associations between recovery and staff support (B = 0.01, 95% CI = 0.01-0.02, ß = 0.39), housing satisfaction (B = 0.15, 95% CI = 0.07-0.22, ß = 0.38), sense of home (B = 0.23, 95% CI = 0.14-0.32, ß = 0.49) and satisfaction with personal economy (B = 0.11, 95% CI = 0.05-0.17, ß = 0.33). Similarly, associations were found between life satisfaction and staff support (B = 0.03, 95% CI = 0.02-0.04, ß = 0.46), housing satisfaction (B = 0.63, 95% CI = 0.46-0.80, ß = 0.60), sense of home (B = 0.65, 95% CI = 0.42-0.87, ß = 0.51) and satisfaction with personal economy (B = 0.34, 95% CI = 0.19-0.50, ß = 0.39).

Originality/value

The findings imply that core issues in supported housing, namely, staff support, housing satisfaction, sense of home and satisfaction with personal economy, are associated with recovery and quality of life.

A qualitative exploration of service users' and staff members' perspectives on the roles of inpatient settings in mental health recovery

Background

Today, international mental health care increasingly focuses on creating recovery-oriented systems of support. This study aims to unravel the daily practice of an inpatient psychiatric ward that engages with persons with complex mental health needs.

Methods

17 in-depth interviews were conducted with patients and staff of the ward. Data was analyzed by means of thematic analysis.

Results

Three important functions of the ward were identified in the participants’ experiences. First, it functions as an asylum, a safe environment where patients can ‘simply be’. Second, the ward is experienced as a particularizing space, as support is organized in an individualized way and patients are encouraged to reconnect with their own identity. Third, the ward functions as a transitional space towards a valuable community life, in which finding adequate housing is of central importance.

Conclusions

The results show that inpatient forms of support tally with personal and social dimensions of recovery and fulfill important roles in recovery-oriented systems of support.

Exploring psychological symptoms and associated factors in patients receiving medication-assisted treatment for opioid-use disorder

BACKGROUND

Patients receiving treatment for opioid-use disorder (OUD) may experience psychological symptoms without meeting full criteria for psychiatric disorders. The impact of these symptoms on treatment outcomes is unclear.

AIMS

To determine the prevalence of psychological symptoms in a cohort of individuals receiving medication-assisted treatment for OUD and explore their association with patient characteristics and outcomes in treatment.

METHOD

Data were collected from 2788 participants receiving ongoing treatment for OUD recruited in two Canadian prospective cohort studies. The Maudsley Addiction Profile psychological symptoms subscale was administered to all participants via face-to-face interviews. A subset of participants (n = 666) also received assessment for psychiatric disorders with the Mini International Neuropsychiatric Interview. We used linear regression analysis to explore factors associated with psychological symptom score.

RESULTS

The mean psychological symptom score was 12.6/40 (s.d. = 9.2). Participants with psychiatric comorbidity had higher scores than those without (mean 16.8 v. 8.6, P<0.001) and 31% of those with psychiatric comorbidity reported suicidal ideation. Higher psychological symptom score was associated with female gender (B = 1.59, 95% CI 0.92-2.25, P<0.001), antidepressant prescription (B = 4.35, 95% CI 3.61-5.09, P<0.001), percentage of opioid-positive urine screens (B = 0.02, 95% CI 0.01-0.03, P<0.001), and use of non-opioid substances (B = 1.92, 95% CI 0.89-2.95, P<0.001). Marriage and employment were associated with lower psychological symptoms.

CONCLUSIONS

Psychological symptoms are associated with treatment outcomes in this population and the prevalence of suicidal ideation is an area of concern. Our findings highlight the ongoing need to optimise integrated mental health and addictions services for patients with OUD.

Ethnographic reflections on access to care services

Purpose

The purpose of this paper is twofold: to explore how gatekeepers’ ways of regulating the researchers’ access to knowledge in/about care services reflect the systemic and interpersonal values that inform Danish welfare systems’ daily workings at the street level; and also explore how the authors’ methodological experiences mirror the value-informed regulatory strategies that professionals and users themselves experience in their daily encounters in the same local practices that the authors have studied.

Design/methodology/approach

The paper takes its empirical point of departure in a multisited ethnographic field study of the management of citizens with complex problems in Danish welfare systems.

Findings

By means of Michael Lipsky’s outline of access regulation, the authors will analyze the following regulatory strategies that are identified during the fieldwork: “Gatekeepers’ sympathy and creaming,” “Queuing and delay,” and ‘Withdrawal of consent and “no resources.” The paper suggests that trust, shared goals and sympathy seem to be key to the process of getting access.

Originality/value

Despite principles of neutrality, equal rights and access to services in welfare systems, the authors’ experiences thus tend to support other research within bureaucratic and care organizations, which has found that interpersonal relations, sympathy, dislikes, norms and values, etc., can heavily influence timely access to services, tailored information and support.

Exploring the Relationships Between Eating Disorders and Mental Health in Women Attending Residential Substance Use Treatment

Objective: Comorbid eating disorders (EDs) and ED symptoms are highly prevalent among women with substance use disorders and may be a barrier to recovery. Higher rates of psychiatric illness are common when more than one disorder is present. Yet little is known about the rates and risk factors for EDs/ED symptoms in women attending treatment centers in Australia. The primary aim is to examine the prevalence of ED symptoms among women attending treatment centers. This study also examines past physical and sexual abuse and mental health as specific predictors of EDs/ED symptoms. Methods: Participants were 1,444 women attending residential treatment for substance use issues provided by the Salvation Army in Australia. Measures included the Addiction Severity Index, the Eating Disorder Screen for Primary Care, medication use, hospitalization, mental health, and past abuse. Results: Alcohol was the primary substance of concern for 53.3% of the women, followed by amphetamines (17.5%), and the mean age was 37.83 years (SD = 10.8). Nearly 60% of women screened positive for ED symptoms and 32% reported a previous or current ED. Women with a history of sexual abuse had significantly greater odds (1.96) of positive screening for an ED compared to those without a history of sexual abuse. Similarly, compared to women without a history of physical abuse, those who did have a history had significantly higher odds (1.59) of a positive screen for an ED. These women were also significantly more likely to have had a health care provider recommend they take medications for psychological or emotional problems in the past 30 days, χ²(1) = 8.42, p = .004, and during their lifetime, χ²(1) = 17.89, p < .001. They also had a significantly greater number of overnight hospitalizations for medical problems compared to those who screened negative, t(137) = -2.19, p = .03. Conclusions: Women with comorbid substance use issues and EDs are highly likely to have a history of past abuse. This combination of comorbidities makes treatment and recovery difficult. Increased awareness and research are required to explore integrated approaches to treatment that accommodate these vulnerabilities and improve long-term outcomes.

Multiple senses of community and recovery processes. A pilot study for a national evaluation of the experiences of persons with substance use problems receiving help and services from Norwegian municipalities

AIMS

This pilot study uses a multifaceted concept of sense of community (SOC)-multiple senses of community (MPSOC)-to understand how the multiple communities of persons with substance use problems, including those with a positive, negative and neutral SOC, influence processes of substance use recovery.

METHODS

Semi-structured interviews were conducted with 16 informants from different Norwegian municipalities and regions. A collaborative research design and thematic analyses with a peer researcher were applied.

RESULTS

The findings confirm prior findings of key ingredients related to recovery. However, they also illustrate that for communities to promote recovery, they need to fulfil individual needs, provide distance from pretreatment status, identity and roles and harmonise with individual meaning systems of an ideal community.

CONCLUSION

Experiences of positive and negative community connections within geographical, relational and ideal communities take part in recovery processes. Community participation is suggested to be included in individual outpatient treatment and posttreatment plans.

Predictors of Mental Health Recovery in Homeless Adults with Mental Illness

For people with mental illness, experiences of homelessness can complicate mental health recovery processes. This study used longitudinal data from a randomized controlled trial of housing first (HF) to examine predictors of recovery among homeless people with mental illness. Findings showed that health and community predictors were most strongly associated with mental health recovery. Receipt of HF did not have any effect on changes in recovery scores at follow-up. Overall, the findings suggest that interventions aimed at preventing chronic homelessness, strengthening social networks and community involvement, and providing case management services will facilitate mental health recovery.

Encountering staff-directed aggression within mental health and substance abuse services: exploring conceptions of practice following education

Background

Staff-directed aggression represents a considerable concern in mental health and substance abuse services, and presents a substantial challenge to the quality and continuity of service provision for people with mental health and substance abuse problems. The practitioners themselves frequently request increased competence as a way to mediate the negative effects of staff-directed violence and aggression. The aim of this study is to explore how practitioners in municipal mental health and substance abuse services conceptualize practice in prevention and management of staff-directed violence. Furthermore, we seek to explore how these conceptions change following participation in two complementary and specially developed courses advancing respectively, qualified risk assessment and situational awareness and disempowerment-sensitive and de-escalation principles for practice.

Method

The study was conducted by using a qualitative phenomenographic research approach. The data-material comprised two-step semi-structured interviews with ten participants from various parts of community mental health and substance abuse services in the Municipality of Oslo, Norway.

Results

The analysis resulted in the development of five qualitatively different, hierarchically ordered, yet logically interrelated conceptual categories of practice concerning prevention and management of staff-directed aggression in community mental health and substance abuse services. These are: (1) Observation, reporting and expectation of organizational intervention, (2) Application of personalized de-escalating skills and behaviour, (3) Delivery of team-based and standardized services, (4) Provision of perceptive and responsive services, and (5) Facilitation of sensitive, involving and reflexive care. The categories vary according to the participants' attentional focus on either the responsibility of the organization, staff members' personally developed skills and techniques, team-based solutions, knowledgeable information processing in making professional judgements and reflexive, interpersonal service provision, as well as according to what meaning participants assign to practice. The authors have identified varying degrees of conceptual change following education in half of the participants.

Conclusion

The results of this study both show that practitioners conceptualize practice in aggressive encounters quite differently. The study also indicate that it is important to consider participant awareness of the phenomenon of interest when devising educational activities for personnel in mental health and substance abuse services.

Return to Work Interventions for Cancer Survivors: A Systematic Review and a Methodological Critique

Cancer patients are more at risk of being unemployed or having difficulties to return to work (RTW) compared to individuals without health concerns, and is thus a major public health issue. The aim of this systematic review is to identify and describe the interventions developed specifically to help cancer patients to RTW after treatment. Two researchers independently screened the articles for inclusion and Critical Appraisal Skills Program (CASP) checklists were used to assess the methodology of the included studies. Ten manuscripts met the inclusion criteria. The type of studies were three quasi-experimental studies, three longitudinal studies, three randomized controlled trials (RCTs) and a qualitative study. RTW interventions were conducted in or outside the hospital (n = 6 and 3 respectively), or both (n = 1). Improvements in RTW were only observed in quasi-experimental studies. No improvement in RTW was noted in RCTs, nor in other measures (e.g., quality of life, fatigue). Lack of statistically significant improvement does not necessarily reflect reality, but may be attributed to non-adapted research methods. This systematic review underscores the need for researches in the RTW field to reach a consensus on RTW criteria and their assessment. Recommendations to this effect are suggested.

The evidence-based group-level symptom-reduction model as the organizing principle for mental health care: time for change?

The content and organization of mental health care have been heavily influenced by the view that mental difficulties come as diagnosable disorders that can be treated by specialist practitioners who apply evidence-based practice (EBP) guidelines of symptom reduction at the group level. However, the EBP symptom-reduction model is under pressure, as it may be disconnected from what patients need, ignores evidence of the trans-syndromal nature of mental difficulties, overestimates the contribution of the technical aspects of treatment compared to the relational and ritual components of care, and underestimates the lack of EBP group-to-individual generalizability. A growing body of knowledge indicates that mental illnesses are seldom "cured" and are better framed as vulnerabilities. Important gains in well-being can be achieved when individuals learn to live with mental vulnerabilities through a slow process of strengthening resilience in the social and existential domains. In this paper, we examine what a mental health service would look like if the above factors were taken into account. The mental health service of the 21st century may be best conceived of as a small-scale healing community fostering connectedness and strengthening resilience in learning to live with mental vulnerability, complemented by a limited number of regional facilities. Peer support, organized at the level of a recovery college, may form the backbone of the community. Treatments should be aimed at trans-syndromal symptom reduction, tailored to serve the higher-order process of existential recovery and social participation, and applied by professionals who have been trained to collaborate, embrace idiography and maximize effects mediated by therapeutic relationship and the healing effects of ritualized care interactions. Finally, integration with a public mental health system of e-communities providing information, peer and citizen support and a range of user-rated self-management tools may help bridge the gap between the high prevalence of common mental disorder and the relatively low capacity of any mental health service.

Pathways to mental health services for young people: a systematic review

PURPOSE

While early access to appropriate care can minimise the sequelae of mental illnesses, little is known about how youths come to access mental healthcare. We therefore conducted a systematic review to synthesise literature on the pathways to care of youths across a range of mental health problems.

METHODS

Studies were identified through searches of electronic databases (MEDLINE, PsycINFO, Embase, HealthSTAR and CINAHL), supplemented by backward and forward mapping and hand searching. We included studies on the pathways to mental healthcare of individuals aged 11-30 years. Two reviewers independently screened articles and extracted data.

RESULTS

Forty-five studies from 26 countries met eligibility criteria. The majority of these studies were from settings that offered services for the early stages of psychosis, and others included inpatient and outpatient settings targeting wide-ranging mental health problems. Generally, youths' pathways to mental healthcare were complex, involved diverse contacts, and, sometimes, undue treatment delays. Across contexts, family/carers, general practitioners and emergency rooms featured prominently in care pathways. There was little standardization in the measurement of pathways.

CONCLUSIONS

Except in psychosis, youths' pathways to mental healthcare remain understudied. Pathways to care research may need to be reconceptualised to account for the often transient and overlapping nature of youth mental health presentations, and the possibility that what constitutes optimal care may vary. Despite these complexities, additional research, using standardized methodology, can yield a greater understanding of the help-seeking behaviours of youths and those acting on their behalf; service responses to help-seeking; and the determinants of pathways. This understanding is critical to inform ongoing initatives to transform youth mental healthcare.

Transforming identity through participation in music and theatre: exploring narratives of people with mental health problems

Background: There is a growing understanding that mental health problems and prolonged contact with mental healthcare systems can affect people’s identities. Working with identity is an important element in mental health recovery.

Purpose: In this article, we explore the significance of participation in a music and theatre workshop in terms of people`s experiences of identity.

Design and methods: This is a qualitative study based on a hermeneutical phenomenological epistemology. Data were collected from in-depth interviews with 11 participants at a music and theater workshop, analysed through a narrative analysis and presented in an ideographical “long” narrative form. The music and theater workshop is not overtly therapeutic although the activity takes place in a Norwegian mental health hospital for adults living with long-term mental health problems.

Results: We identified three crosscutting themes: (1) becoming a whole person, (2) being allowed to hold multiple identities and (3) exploring diverse perspectives.

Conclusion: Findings show that participation in the music and theatre workshop transformed the participants’ experiences of identity on two levels: individually and collectively. The participants developed a broader picture of themselves through their creative work with others. When they developed new identities, the narratives of themselves expanded.

Dilemmas in recovery-oriented practice to support people with co-occurring mental health and substance use disorders: a qualitative study of staff experiences in Norway

Background

Recovery-oriented practice is recommended in services for people with co-occurring mental health and substance use disorders. Understanding practitioners’ perceptions of recovery-oriented services may be a key component of implementing recovery principles in day-to-day practice. This study explores and describes staff experiences with dilemmas in recovery-oriented practice to support people with co-occurring disorders.

Methods

Three focus group interviews were carried out over the course of 2 years with practitioners in a Norwegian community mental health and addictions team that was committed to developing recovery-oriented services. Thematic analysis was applied to yield descriptions of staff experiences with dilemmas in recovery-oriented practice.

Results

Three dilemmas were described: (1) balancing mastery and helplessness, (2) balancing directiveness and a non-judgmental attitude, and (3) balancing total abstinence and the acceptance of substance use.

Conclusions

Innovative approaches to practice development that address the inherent dilemmas in recovery-oriented practice to support people with co-occurring disorders are called for.

Electronic supplementary material

The online version of this article (10.1186/s13033-018-0211-5) contains supplementary material, which is available to authorized users.

Initiating and maintaining a recovery process – experiences of persons with dual diagnosis

Purpose

The purpose of this paper is to investigate the internal and social factors that persons with experience from severe mental illness and alcohol and other drugs problems, and who have received treatment for these problems, describe as important for initiating and maintaining a recovery process.

Design/methodology/approach

In total, 40 persons were interviewed and asked to describe factors they perceived as important for initiating and maintaining recovery. The software Nvivo was used to categorise data in internal and social factors with subcategories.

Findings

There is significant variation in how recovery emerged but involved in general having a proper social situation and finding meaning in life. Initially, the majority had a marginalised situation with need of assistance with housing, employment, financial and social support.

Research limitations/implications

The change process in the investigated group is interpreted as related to individual resources rather than belonging to a group defined as having “double trouble”.

Practical implications

The study implies that in addition to professional help to handle diagnosed problems, the group in focus also need support and interventions that address individual complex needs.

Social implications

Supporting activities/peer support seem to be important for those lacking support from family. At the same time, it is important to recognise the risk of being forced into a recovery identity which might lead to worsening the situation for those who do not fit into this.

Originality/value

By using the same design as in previous studies, comparisons with other groups are possible while still keeping the qualitative meaning of the investigated factors.

Building trust and recovery capital: the professionals’ helpful practice

Purpose

The possibility of recovery for persons with co-occurring addiction and mental health problems has been contested. Though, recent studies show that recovery might happen, but without connection to specific treatment interventions. The purpose of this paper is to analyse professionals’ perceptions of their contribution to improvement.

Design/methodology/approach

In all, 15 experienced professionals were interviewed. The interviews were analysed using thematic analysis.

Findings

Recovery processes were dependent of the persons’ access to different forms of recovery capital (RC). Lack of RC was often associated with lack of trust in one’s self and others (identity and personal capital). Professionals had to be accepted as trustful agents through co-creating changes in the person’s life. Trusting a professional might be a basis for trusting one’s self as an agent in one’s recovery process and develop a social network (identity and relationship capital). Other aspects stressed by the professionals were to manage their own fragmentized organisations and societal shortcomings (economic capital).

Practical implications

Recovery has been described as a profoundly individual journey. However, it is also deeply social, involving other persons and contextual factors. Focusing on just one level might counteract the complex work behind double recovery.

Originality/value

Improvement was described as dependent on the presence of personal, inter-personal, organisational and societal factors. The findings give a deep and concrete understanding of the process constituting the development of a working alliance and its dependence on factors outside the direct relation between the staff member and the person.

Promoting recovery from severe mental illness: Implications from research on metacognition and metacognitive reflection and insight therapy

Research indicates that individuals with schizophrenia recover. Recovery, however means different things to different individuals and regardless of what kind of experiences define recovery, the individual diagnosed with the serious mental illness must feel ownership of their recovery. This raises the issue of how mental health services should systematically promote recovery. This paper explores the practical implications for research on metacognition in schizophrenia for this issue. First, we present the integrated model of metacognition, which defines metacognition as the spectrum of activities which allow individual to have available to themselves an integrated sense of self and others as they appraise and respond to the unique challenges they face. Second, we present research suggesting that many with schizophrenia experience deficits in metacognition and that those deficits compromise individuals’ abilities to manage their lives and mental health challenges. Third, we discuss a form of psychotherapy inspired by this research, Metacognitive Reflection and Insight Therapy which assists individuals to recapture the ability to form integrated ideas about themselves and others and so direct their own recovery. The need for recovery oriented interventions to focus on process and on patient’s purposes, assess metacognition and consider the intersubjective contexts in which this occurres is discussed.

Narratives of recovery in people with coexisting mental health and alcohol misuse difficulties

Purpose

Existing literature has examined what recovery means to people with co-occurring difficulties, but does little to examine experiences of recovery as a process. The purpose of this paper is to use a narrative approach to explore the process of recovery as an individual journey in a social context. It focuses on people who use alcohol in order to explore the impact of alcohol’s specific cultural meanings on the recovery journey.

Design/methodology/approach

Ten interviews with people with coexisting mental health and alcohol misuse difficulties were conducted, audio-recorded, and transcribed. The transcriptions were analysed using narrative analysis.

Findings

Most participants’ narratives shared a three-part structure, from a traumatic past, through an episode of change, to an ongoing recovery phase. Change and recovery were attributed to several factors including flexible and practical support from services, therapeutic relationships with key professionals, and peer support. Some participants redefined themselves and their alcohol use in relation to ideas of what it is to be “normal”.

Research limitations/implications

The research excluded people who recover outside of services, replicating a shortcoming of much research in this area.

Practical implications

The value placed on professionals having specialised therapeutic skills in working with trauma highlights the need for training in this area. The role for practical and material support underlines the importance of multi-agency working.

Originality/value

The narrative methodology enables the study to draw links between personal stories of recovery and wider social influences, allowing comment on the implications for services. Further, the experiences of people with coexisting mental health and alcohol misuse difficulties have rarely been studied apart from the dual diagnosis population in general, so this paper is able to investigate the specific challenges for this population.

Developing Substance Use Programming for Person-Oriented Recovery and Treatment (SUPPORT): protocol for a pilot randomized controlled trial

BACKGROUND

There is a lack of evidence-based substance use disorder treatment and services targeting returning inmates. Substance Use Programming for Person-Oriented Recovery and Treatment (SUPPORT) is a community-driven, recovery-oriented approach to substance abuse care which has the potential to address this service gap. SUPPORT is modeled after Indiana's Access to Recovery program, which was closed due to lack of federal support despite positive improvements in clients' recovery outcomes. SUPPORT builds on noted limitations of Indiana's Access to Recovery program. The ultimate goal of this project is to establish SUPPORT as an effective and scalable recovery-oriented system of care. A necessary step we must take before launching a large clinical trial is pilot testing the SUPPORT intervention.

METHODS

The pilot will take place at Public Advocates in Community Re-Entry (PACE), nonprofit serving individuals with felony convictions who are located in Marion County, Indiana (Indianapolis). The pilot will follow a basic parallel randomized design to compare clients receiving SUPPORT with clients receiving standard services. A total of 80 clients within 3 months of prison release will be recruited to participate and randomly assigned to one of the two intervention arms. Quantitative measures will be collected at multiple time points to understand SUPPORT's impact on recovery capital and outcomes. We will also collect qualitative data from SUPPORT clients to better understand their program and post-discharge experiences.

DISCUSSION

Successful completion of this pilot will prepare us to conduct a multi-site clinical trial. The ultimate goal of this future work is to develop an evidence-based and scalable approach to treating substance use disorder among persons returning to society after incarceration.

TRIAL REGISTRATION

ClinicalTrials.gov (Clinical Trials ID: NCT03132753 and Protocol Number: 1511731907). Registered 28 April 2017.