Consumers' understanding and expectations of a community-based recovery-oriented mental health rehabilitation unit: a pragmatic grounded theory analysis

Constructing recovery: A Lived Experience and post-structuralist exploration of how the meaning of personal recovery and rehabilitation has changed over time

OBJECTIVE

This article explores how the concept of 'recovery' has been much debated and often sits at odds with our notion of rehabilitation.

METHOD

This article provides a Lived Experience and post-structural commentary on the ever-changing meaning of recovery and rehabilitation.

RESULTS

Building on the contemporary Consumer Movement's use of the term recovery, this article explores how constructions of recovery try to create a boundary which stops people being invalidated based on their experience, or perceived experience, of mental distress. The concept of recovery has insufficiently influenced rehabilitation practices. Recovery is also frequently reappropriated, often with no or minimal consumer input, and reconstructed in line with notions of progress and improvement.

CONCLUSION

People with Lived Experience have challenged the concept of rehabilitation; however, rehabilitation may still have relevance if it is redefined according to Lived Experience values and recovery-oriented practice.

Recovery-Oriented Practices in Community-based Mental Health Services: A Systematic Review

Objective: New initiatives are needed to manage patients with mental health problems in the community. Among the core principal ideals of any healthcare system is transition from traditional services to community-based practices. The aim of this study was to assess community-based and recovery-oriented practices and interventions for individuals with mental health problems. Method : MESH keywords, including "mental health recovery", "rehabilitation", "aftercare", "community psychiatry", and "mental health service" were searched in scientific databases such as Medline, EMBASE, PsychInfo, CINAHL, and Cochrane up to July 2022. A snowball search was also conducted on eligible studies. The methodological quality of the studies was determined by Kmet standard criteria. Results: The systematic review included 32 studies, all of which demonstrated a moderate to high promising effect for community-based and recovery-oriented practices or programs on patients with severe mental illness. These practices could help patients to find suitable jobs, avoid isolation and stigma, improve communication skills, increase awareness of problems, and foster independence. The study also highlighted the pivotal role of nurses, artistic and sports activities, electronic (E)-mental health, home visits, psychoeducation, and special recovery programs. Conclusion: Community-based and recovery-oriented practices should be used as an effective means of normalizing the lives of psychiatric patients. In essence, by cultivating hope and empowering these patients, many of the concerns of health systems can be eradicated.

Comparative Effectiveness of Integrated Peer Support and Clinical Staffing Models for Community-Based Residential Mental Health Rehabilitation: A Prospective Observational Study

This observational study compared the outcomes of consumers receiving community-based residential mental health rehabilitation support in Australia under a clinical staffing model and an integrated staffing model where Peer Support Workers are the majority component of the staffing profile. Reliable and clinically significant (RCS) change between admission and discharge in functional and clinical assessment measures were compared for consumers receiving care under the clinical (n = 52) and integrated (n = 93) staffing models. Covariate analyses examined the impact of known confounders on the outcomes of the staffing model groups. No statistically significant differences in RCS improvement were identified between the staffing models. However, logistic regression modelling showed that consumers admitted under the integrated staffing model were more likely to experience reliable improvement in general psychiatric symptoms and social functioning. The findings support the clinical and integrated staffing models achieving at least equivalent outcomes for community-based residential rehabilitation services consumers.

"Why I stay in community psychiatric rehabilitation": a semi-structured survey in persons with schizophrenia

AIMS

Although community psychiatric rehabilitation plays an important role in returning persons with schizophrenia to the society, many patients in China stay in rehabilitation centers for longer periods of time and subsequently fail to integrate. This study is aimed to explore the underlying causes of this trend and identify possible solutions.

METHODS

This study used a qualitative descriptive design to examine the persons with schizophrenia who stay in rehabilitation centers for longer periods of time. The researchers conducted semi-structured telephone interviews with the patients recruited through purposeful sampling. The audio-recorded interviews were transcribed in transcripts in Chinese. Thematic analysis was performed using Colaizzi's 7-step method.

RESULTS

Most patients believe that they have gained knowledge, improved skills, friendship and social circles through community mental rehabilitation, with the sense of belonging and enriched life strongly attracting them to the rehabilitation centers. They felt that the difficulty of further integration into society is mainly because of social prejudice and rejection. In addition, the activities of community mental rehabilitation meet the needs of social communication, which also hinder patients from further entering the society.

CONCLUSIONS

Persons with schizophrenia with long-term stay in community mental rehabilitation centers meet their friendship, sense of belonging and social needs by participating in rehabilitation activities. Providing special social opportunity for these patients can get them out of the rehabilitation center. Overall, it is possible for patients to gradually return to society in a collective form.

The Contribution of a Music and Arts Rehabilitation Program to the Creative Identity, Well-Being, and Community Integration of People With Mental Health Conditions

The United Nations highlighted the importance of promoting the rights of people with mental health conditions (MHC) to education, employment, and citizenship. One related initiative in Israel is the Garage pre-academic music and arts school for individuals with musical and artistic abilities coping with MHC. This process–outcome study examined whether and how the Garage contributes to participants’ creative self-concept, mental health, alleviates loneliness, and promotes postsecondary education and work integration. It also probed the participants’ initial expectations and the extent to which these were fulfilled. Using a single-group pretest–posttest design, quantitative data on the outcome variables were collected, along with mid-test data on process variables from the Garage students ( N = 44). Supplementary qualitative data were collected at pretest on the students’ expectations. The results suggest a significant increase in creative personal identity and mental health, a decrease in loneliness, and promotion of postsecondary education and work integration. These findings were associated with persistent attendance, basic psychological needs satisfaction, and expectation fulfillment. A merged analysis indicated that the students’ qualitative expectations were generally congruent with the quantitative results. Overall, the findings show how the program corresponds to humanistic values, targets service users’ needs and rights, and promotes personal recovery and community integration.

Cross-Sectional Comparison of Treatment Provided Under the Clinical, Integrated, and Partnership Staffing Models for Community-Based Residential Mental Health Rehabilitation

In Queensland (Australia), community-based residential mental health rehabilitation services have three distinct staffing profiles. The traditional 'clinical' staffing model has nursing staff occupying most staff roles. The 'partnership' approach involves collaboration between the health service and a Non-Government Organisation. Under the 'integrated' staffing approach, Peer Support Workers reflect the majority staffing component. This study compares the treatment received by consumers (N = 172) under these staffing models using cross-sectional administrative data. Staffing models were generally comparable on demographic, diagnostic, and symptomatic/impairment measures. However, statistically significant differences were present on a range of treatment variables. Differences mainly occurred between the clinical and integrated approaches, with the integrated staffing model having lower rates of involuntary treatment, antipsychotic polypharmacy, depot use, and chlorpromazine dose equivalence levels. These findings indicate the need to carefully examine the impact of staffing configuration on rehabilitation processes to understand whether differences in approaches are likely to impact rehabilitation outcomes.

A systematic review of measures assessing mental health professionals' perspectives of recovery

Recovery is internationally recognized as a concept to improve the well-being of consumers. Compared with the numerous measures assessing consumer perspectives of recovery, only a few measures have been developed to assess Mental Health Professionals' (MHPs) perspectives of recovery to inform practice. The present study aims to systematically review the literature to identify existing measures designed to assess MHPs' perspectives of recovery and evaluate their psychometric properties, and the methodological considerations of the design and use of these measures. We searched literature across eight electronic databases: MEDLINE, Web of Science, PsycINFO, PsyArticles, CINAHL, Scopus, EMBASE, and Google scholar. We identified 2631 articles across all databases. Of these, 40 articles met the inclusion criteria, which comprised 14 original measures assessing mental health recovery and 26 articles reassessing the psychometric properties of the original 14 measures. Our results suggested that while there are existing measures for assessing MHPs' perspectives of recovery, only a few of these measures met standard evaluation criteria for psychometric properties. Specifically, the validation of the identified measures is still in its infancy. For example, the easiness of applying the measures differs among the studies, and only a few of the measures fully involved consumers in the scale development phase. The implication of the findings for future use and development of recovery measures in mental health practice and research are discussed and recommended.

Consumer experiences of community-based residential mental health rehabilitation for severe and persistent mental illness: A pragmatic grounded theory analysis

Semi-structured interviews were used to explore the consumer experience of community-based residential mental health rehabilitation support at Community Care Units in Australia. These clinical services provide recovery-oriented residential rehabilitation to people affected by severe and persistent mental illness. Typically, nurses occupy the majority of staff roles. However, two of the three sites in the study were trialling a novel integrated staffing model where the majority of staff were people with a lived experience of mental illness employed as peer support workers (PSWs). The interviews explored consumers' experiences of care 12-18 months after admission. Fifteen interviews were completed with an independent interviewer. Most participants were diagnosed with schizophrenia or a related psychotic disorder. The analysis followed a pragmatic approach to grounded theory. Consumers viewed the CCU favourably, emphasizing the value of the relationships formed with staff and co-residents. No major differences in consumers' experience under the traditional versus integrated staffing models were identified; however, those from the integrated staffing model sites valued the contributions of the peer support workers. The understanding of the consumer experience emerging through this study aligned with their expectations of the service at the time of commencement.

Recovery services and expectation of consumers and mental health professionals in community-based residential facilities of Ghana

BACKGROUND

In the past decades, considerable global attention has been drawn to recovery services that seek to promote the personal recovery journey of consumers with mental illness. However, in most settings, including Ghana, limited empirical studies have attempted to explore, from the perspectives of Mental Health Professionals (MHPs) and consumers, the effectiveness of recovery services and expectation towards the recovery. This study, therefore, explored consumers' and MHPs perspectives concerning recovery services and expectations towards recovery in two community-based residential facilities in Ghana.

METHODS

A qualitative method, involving in-depth interviews and observations, were used to collect data from 24 participants (5 MHPs and 19 consumers). Thematic analysis was used to analyze the data.

RESULTS

The study identified three global themes and nine organizing themes. The global themes were recovery services offered to consumers, expectation regarding personal recovery and challenges in achieving recovery. The study found that recovery services were expected to improve the internal and external recovery processes of consumers. The internal recovery process was independent living whilst the external recovery process were management of illness, economic empowerment and social inclusion. Several systemic and consumer-related factors influenced consumers' and MHPs expectation concerning the recovery journey.

CONCLUSION

The study concludes that the government should prioritize the use of recovery services through policies, financial incentives, infrastructure support, and adequate training of MHPs.

The impact of Recovery Colleges on mental health staff, services and society

AIMS

Recovery Colleges are opening internationally. The evaluation focus has been on outcomes for Recovery College students who use mental health services. However, benefits may also arise for: staff who attend or co-deliver courses; the mental health and social care service hosting the Recovery College; and wider society. A theory-based change model characterising how Recovery Colleges impact at these higher levels is needed for formal evaluation of their impact, and to inform future Recovery College development. The aim of this study was to develop a stratified theory identifying candidate mechanisms of action and outcomes (impact) for Recovery Colleges at staff, services and societal levels.

METHODS

Inductive thematic analysis of 44 publications identified in a systematised review was supplemented by collaborative analysis involving a lived experience advisory panel to develop a preliminary theoretical framework. This was refined through semi-structured interviews with 33 Recovery College stakeholders (service user students, peer/non-peer trainers, managers, community partners, clinicians) in three sites in England.

RESULTS

Candidate mechanisms of action and outcomes were identified at staff, services and societal levels. At the staff level, experiencing new relationships may change attitudes and associated professional practice. Identified outcomes for staff included: experiencing and valuing co-production; changed perceptions of service users; and increased passion and job motivation. At the services level, Recovery Colleges often develop somewhat separately from their host system, reducing the reach of the college into the host organisation but allowing development of an alternative culture giving experiential learning opportunities to staff around co-production and the role of a peer workforce. At the societal level, partnering with community-based agencies gave other members of the public opportunities for learning alongside people with mental health problems and enabled community agencies to work with people they might not have otherwise. Recovery Colleges also gave opportunities to beneficially impact on community attitudes.

CONCLUSIONS

This study is the first to characterise the mechanisms of action and impact of Recovery Colleges on mental health staff, mental health and social care services, and wider society. The findings suggest that a certain distance is needed in the relationship between the Recovery College and its host organisation if a genuine cultural alternative is to be created. Different strategies are needed depending on what level of impact is intended, and this study can inform decision-making about mechanisms to prioritise. Future research into Recovery Colleges should include contextual evaluation of these higher level impacts, and investigate effectiveness and harms.

A systematic review of service models and evidence relating to the clinically operated community-based residential mental health rehabilitation for adults with severe and persisting mental illness in Australia

BACKGROUND

Clinically operated community-based residential rehabilitation units (Community Rehabilitation Units) are resource intensive services supporting a small proportion of the people with severe and persisting mental illness who experience difficulties living in the community. Most consumers who engage with these services will be diagnosed with schizophrenia or a related disorder. This review seeks to: generate a typology of service models, describe the characteristics of the consumers accessing these services, and synthesise available evidence about consumers' service experiences and outcomes.

METHOD

A systematic review was undertaken to identify studies describing Community Rehabilitation Units in Australia, consumer characteristics, and evidence about consumer experiences and outcomes. Search strings were applied to multiple databases; additional records were identified through snowballing. Records presenting unique empirical research were subject to quality appraisal.

RESULTS

The typology defined two service types, Community-Based Residential Care (C-BRC), which emerged in the context of de-institutionalisation, and the more recent Transitional Residential Rehabilitation (TRR) approach. Key differentiating features were the focus on transitional care and 'recovery' under TRR. Schizophrenia spectrum disorders were the most common primary diagnosis under both service types. TRR consumers were more likely to be male, referred from community settings, and less likely to be subject to involuntary treatment. Regarding outcomes, the limited quantitative evidence (4 records, 2 poor quality) indicated C-BRC was successful in supporting the majority of consumers transferred from long-term inpatient care to remain out of hospital. All qualitative research conducted in C-BRC settings was assessed to be of poor quality (3 records). No methodologically sound quantitative evidence on the outcomes of TRR was identified. Qualitative research undertaken in these settings was of mixed quality (9 records), and the four records exploring consumer perspectives identified them as valuing the service provided.

CONCLUSIONS

While there is qualitative evidence to suggest consumers value the support provided by Community Rehabilitation Units, there is an absence of methodologically sound quantitative research about the consumer outcomes achieved by these services. Given the ongoing and increasing investment in these facilities within the Australian context, there is an urgent need for high-quality research examining their efficiency and effectiveness.

TRIAL REGISTRATION

PROSPERO ( CRD42018097326 ).

Staff Expectations of an Australian Integrated Model of Residential Rehabilitation for People With Severe and Persisting Mental Illness: A Pragmatic Grounded Theory Analysis

Mental health services increasingly involve peer support workers. Staff expectations of working in these services are important because they frame processes and cultures that develop within services, and influence work satisfaction, staff retention, and consumer experience. We examined staff expectations at two new community-based residential rehabilitation units trialing a staffing model where most staff are employed based on their lived experience of mental illness. Qualitative semi-structured interviews were conducted with ten peer support workers and five clinical staff on commencement at Community Care Units that opened in 2014 and 2015. Staff views covered individual motivations, emerging organizational practices and culture, and the nature and philosophy of recovery and recovery-oriented rehabilitation. Subtle differences were evident in staff understandings of recovery and recovery-oriented rehabilitation. Staff were mostly optimistic about the services' potential but expressed uncertainty about how the professions would work together and practicalities of the new roles. Concerns that staff foreshadowed are consistent with those reported in the literature and can be pre-emptively addressed. Future research on staff experiences will enhance understanding of how staff perceptions of recovery-oriented rehabilitation change over time, and of how these relate to consumer experiences and outcomes.

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

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