How effective is the comprehensive approach to rehabilitation (CARe) methodology? A cluster randomized controlled trial

Process evaluation of a comprehensive approach to reintegration of disability benefit recipients with multiple problems (CARm) into the labour market

PURPOSE

As the effect evaluation of our randomized controlled trial the "Comprehensive Approach of Reintegration for clients with Multiple problems" (CARm) showed no superior effect on re-integration into paid employment of the clients when compared with clients of the care as usual, we conducted this process evaluation to gain insight into whether the intervention was conducted according to protocol.

METHODS

Using questionnaires on recruitment, reach, dose delivered, dose received, fidelity, context, and satisfaction we collected data from 40 labour experts of the Public Employment Service of the Dutch Social Security Institute, and from 166 disability benefit recipients dealing with multiple problems.

RESULTS

Only few of the labour experts provided the key elements of the intervention to their clients. Between the clients of both groups were no significant differences in the dose received. More than half of the labour experts of the intervention group reported organizational changes.

CONCLUSION

The lack of effect of the CARm intervention was almost certainly caused by implementation failure. Once again this study showed the importance of involving all stakeholders in developing and the conduct of the intervention, and of clarifying the consequences for the organization, to ensure that it can be conducted according to protocol.

Effectiveness of a needs-tailored nurse-led recovery program for community-dwelling people with schizophrenia: a cluster-randomized controlled trial

BACKGROUND

Meeting people's needs is positively correlated with their recovery. However, recovery services rarely include nurse-led programs tailored to the needs of these people. This study aimed to evaluate the effectiveness of a new needs-tailored recovery program by using a cluster-randomized controlled trial design.

METHODS

We conducted a parallel randomized controlled trial in two community psychiatric departments, employing nurse-level clustering for intervention delivery and selecting participants through convenience sampling. The participants were people diagnosed with schizophrenia that were receiving homecare services. The experimental group (n = 82) received needs-tailored recovery program for six months. The control group (n = 82) received traditional homecare. Data were collected at baseline, post-intervention, and the three-month follow-up (the study ran from February to December 2021). The outcomes were recovery, needs, hope, empowerment, psychotic symptoms, and medication adherence. We used repeated measures ANOVA tests to examine the effect of the group × time interaction.

RESULTS

The participants in the experimental group demonstrated statistically significant improvements in recovery, hope, and medication adherence compared to the control group, both immediately post-intervention and at the three-month follow-up. Moreover, they exhibited statistically significant reductions in needs compared to the control group at the three-month follow-up (p < .05). While the interaction effect for psychotic symptoms was not significant, the time effect was significant (p < .05). No significant interaction or time effect was observed for empowerment.

CONCLUSION

The findings increase our understanding of recovery-oriented care that prioritizes therapeutic alliance, integrated needs assessment, individual goals, hope, and empowerment.

TRIAL REGISTRATION

The Clinicaltrials.gov identifier NCT05304780 retrospectively registered on 03/31/2022.

Shifting Mindsets: The Impact of a Patient Portal on Functioning and Recovery in a Mental Health Setting

OBJECTIVE

This study aims to understand whether higher use of a patient portal can have an impact on mental health functioning and recovery.

METHOD

A mixed methods approach was used for this study. In 2019-2021, patients with mental health diagnoses at outpatient clinics in an academic centre were invited to complete World Health Organization Disability Assessment Scale 12 (WHODAS-12) and Mental Health Recovery Measure surveys at baseline, 3 months, and 6 months after signing up for the portal. At the 3-month time point, patients were invited to a semistructured interview with a member of the team to contextualize the findings obtained from the surveys. Analytics data was also collected from the platform to understand usage patterns on the portal.

RESULTS

Overall, 113 participants were included in the analysis. There was no significant change in mental health functioning and recovery scores over the 6-month period. However, suboptimal usage was observed as 46% of participants did not complete any tasks within the portal. Thirty-five participants had low use of the portal (1-9 interactions) and 18 participants had high usage (10+ interactions). There were also no differences in mental health functioning and recovery scores between low and high users of the portal. Qualitative interviews highlighted many opportunities where the portal can support overall functioning and mental health recovery.

CONCLUSIONS

Collectively, this study suggests that higher use of a portal had no impact, either positive or negative, on mental health outcomes. While it may offer convenience and improved patient satisfaction, adequate support is needed to fully enable these opportunities for patient care. As the type of interaction with the portal was not specifically addressed, future work should focus on looking at ways to support patient engagement and portal usage throughout their care journey.

Community-based models of care facilitating the recovery of people living with persistent and complex mental health needs: a systematic review and narrative synthesis

Objective

This study aims to assess the effectiveness of community-based models of care (MoCs) supporting the recovery of individuals who experience persistent and complex mental health needs.

Method

We conducted a systematic review and narrative synthesis of MoC studies reporting clinical, functional, or personal recovery from October 2016 to October 2021. Sources were Medline, EMBASE, PsycInfo, CINAHL, and Cochrane databases. Studies were grouped according to MoC features. The narrative synthesis was led by our researchers with lived experience.

Results

Beneficial MoCs ranged from well-established to novel and updated models and those explicitly addressing recovery goals and incorporating peer support: goal-focused; integrated community treatment; intensive case management; partners in recovery care coordination; rehabilitation and recovery-focused; social and community connection-focused; supported accommodation; and vocational support. None of our diverse group of MoCs supporting recovery warranted a rating of best practice. Established MoCs, such as intensive case management, are promising practices regarding clinical and functional recovery, with potential for enhancements to support personal recovery. Emerging practice models that support personal and functional recovery are those where consumer goals and priorities are central.

Conclusion

Evidence for established models of care shows that there is a need for inevitable evolution and adaptation. Considering the high importance of effective MoCs for people experiencing persistent and complex mental health needs, further attention to service innovation and research is required. Greater emphasis on the inclusion of lived and living experience in the design, delivery, implementation, and research of MoCs is needed, to enhance MOCs' relevance for achieving individual consumer recovery outcomes.

Exploring the factors that predict quality of life, and the relationship between recovery orientation and quality of life in adults with severe mental health difficulties

Integration of intrapersonal, interpersonal and environmental factors has been proposed to enhance understanding of psychological quality of life (QOL) in adults with severe and enduring mental illness (SMI). This study examined the contribution of factors such as self-stigma, coping style and personal recovery orientation to psychological QOL in SMI; compared QOL outcomes to norms from the general population; and examined the association between personal recovery orientation and overall QOL. 70 participants with SMI completed measures of QOL (including psychological QOL), personal recovery orientation, coping, perceived stigma, psychological distress and demographic variables. Regression analysis found that only adaptive coping and psychological distress contributed significantly to psychological QOL. Personal recovery orientation was significantly associated with overall subjective QOL. Participants had lower QOL in the psychological and social relationships domains compared to the general population. Findings support the positive contribution of adaptive coping to psychological QOL, and the positive association between personal recovery orientation and overall QOL.

Comprehensive approach to reintegration of disability benefit recipients with multiple problems (CARm) into the labour market: results of a randomized controlled trial

PURPOSE

Although most clients on work disability benefits face multiple problems, most traditional interventions for (re)integration focus on a single problem. The aim of this study was to evaluate the "Comprehensive Approach to Reintegrate clients with multiple problems" (CARm), which provides a strategy for labour experts to build a relationship with each client in order to support clients in their needs and mobilize their social networks.

METHODS

This study is a stratified, two-armed, non-blinded randomized controlled trial (RCT), with a 12-month follow-up period. Outcome measures were: having paid work, level of functioning, general health, quality of life, and social support.

RESULTS

We included a total of 207 clients in our study; 97 in the intervention group and 110 in the care as usual (CAU) group. The clients' mean age was 35.4 years (SD 12.8), 53.1% were female, and 179 (86.5%) reported multiple problems. We found the CARm intervention to have no significant effects superior to those of the CAU group on all outcomes.

CONCLUSION

As we found no superior effect of the CARm intervention compared to CAU, we cannot recommend widespread adoption of CARm. A process evaluation will give more insight into possible implementation failure of the intervention. IMPLICATIONS FOR REHABILITATIONMost traditional interventions for (re)integration into the labour market are problem-centred, i.e., focusing on a single problem, and have limited effectiveness in persons with multiple problems.A strength-based intervention may be suitable for vocational rehabilitation and disability settings, since it contains many elements (e.g., being strength-based, focused on clients' wishes and goals, and involving activation of the social environment) also likely to improve chances of re-employment of persons with multiple problems.In this study a strength-based intervention did not show a superior effect on paid employment and functioning within one year follow-up compared to care as usual in people with multiple problems on a work disability benefit.

Community-based social interventions for people with severe mental illness: a systematic review and narrative synthesis of recent evidence

People living with severe mental illness (SMI) are one of the most marginalized groups in society. Interventions which aim to improve their social and economic participation are of crucial importance to clinicians, policy-makers and people with SMI themselves. We conducted a systematic review of the literature on social interventions for people with SMI published since 2016 and collated our findings through narrative synthesis. We found an encouragingly large amount of research in this field, and 72 papers met our inclusion criteria. Over half reported on the effectiveness of interventions delivered at the service level (supported accommodation, education or employment), while the remainder targeted individuals directly (community participation, family interventions, peer-led/supported interventions, social skills training). We identified good evidence for the Housing First model of supported accommodation, for the Individual Placement and Support model of supported employment, and for family psychoeducation, with the caveat that a range of models are nonetheless required to meet the varied housing, employment and family-related needs of individuals. Our findings also highlighted the importance of contextual factors and the need to make local adaptations when "importing" interventions from elsewhere. We found that augmentation strategies to enhance the effectiveness of social interventions (particularly supported employment and social skills training) by addressing cognitive impairments did not lead to transferable "real life" skills despite improvements in cognitive function. We also identified an emerging evidence base for peer-led/supported interventions, recovery colleges and other interventions to support community participation. We concluded that social interventions have considerable benefits but are arguably the most complex in the mental health field, and require multi-level stakeholder commitment and investment for successful implementation.

The level of formal support received by people with severe mental illness living in supported accommodation and participation: A systematic review

AIM

The review aimed to identify and explore the association of level of support received by people with severe mental illness in supported accommodation and participation.

METHOD

The authors conducted a systematic search in MEDLINE, PsychINFO, PsychARTICLES, CINAHL Plus and ASSIA. Searches were restricted to articles published in English and participants aged 18 years and over with severe mental illness. Articles were included based on level of support received in mental health supported accommodation, classified according to the Simple Taxonomy for Supported Accommodation, and three factors of participation: social participation, daily living functioning and personal empowerment. Studies of in-patient settings and nursing homes were excluded. The review protocol is registered on PROSPERO (registration number: CRD42019161808).

RESULTS

Six articles were included in the review from USA, Australia, Sweden and Taiwan. Factors of participation for people living in accommodation with moderate support and accommodation with high support were explored. Data indicated an association between level of support and participation showing that people living in accommodation with moderate support had increased participation compared to people living in accommodation with high support.

CONCLUSION

This review identified an association between level of formal support and participation. People with SMI living in accommodation with medium support participated in more community occupations, more activities and had a higher level of personal empowerment than people living in accommodation with high support.

A qualitative emancipatory inquiry into relationships between people with mental disorders and health professionals

WHAT IS KNOWN ON THE SUBJECT?: A therapeutic alliance with people with mental disorders could help increase the efficacy of treatment. The paradigm shift from a paternalistic model to one that respects the person's autonomy has led to professionals accepting the active role of people with mental disorders making decisions that affect their treatment. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: People with mental disorders perceive paternalistic and stigmatizing attitudes from health professionals, and they do not feel involved in decisions about their health, which can render effective therapeutic alliances difficult. The findings reveal that although people in Mediterranean countries are used to paternalistic treatment from health professionals due to cultural factors, people with mental disorders are increasingly critical of how they are treated and demand greater autonomy and respect in the decision to undergo drug therapy. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: In their interactions with people with mental disorders, health professionals should include efforts aimed at improving shared decision-making capabilities and avoiding paternalistic or stigmatizing attitudes. ABSTRACT: Introduction A therapeutic alliance with people is essential for the efficacy of treatments. However, the traditional paternalistic values of the Mediterranean society may be incompatible with patient autonomy. Aim To explore the therapeutic relationship from the perspective of people diagnosed with mental disorders with health professionals, including nurses. Methods This emancipatory research was performed through focus groups, with people with mental disorders who had a variety of diagnoses and experiences of acute and community-based mental health services and other healthcare services. Data were analysed using the content analysis method. Results Four main themes emerged: stereotypes and prejudice; quality of interactions and treatment; emotional and behavioural impacts; and demands. Discussion According to the participants' descriptions, health professionals are not exempt from prejudice against persons with psychiatric diagnoses. They reported experiencing abuse of power, malpractice, and overmedication. Thus, in the Mediterranean culture, professional attitudes may represent a barrier for an appropriate therapeutic alliance, and people with mental disorders do not feel involved in making decisions about their health. Implications for practice Knowing how people with mental disorders perceive their interactions with health professionals and the effects is necessary to move the care model towards more symmetric relationships that facilitate a therapeutic alliance.

A Systematic Review of the Characteristics and Efficacy of Recovery Training for Mental Health Staff: Implications for Supported Accommodation Services

Evidence suggests a link between recovery-oriented practise and service user outcomes in supported accommodation settings. Current clinical guidelines recommend recovery training for supported accommodation staff, however evidence relating to the effectiveness of this type of training is unclear. This review aimed to describe and compare the characteristics and efficacy of existing recovery training packages for mental health staff. The appropriateness and applicability of the interventions was considered in relation to UK supported accommodation services. Initial search processes returned 830 papers. After duplicate removal, inclusion and exclusion criteria were applied to 489 papers, leaving a final sample of seven papers. Data were reviewed using a narrative synthesis approach. The reviewed papers showed variation in the aims, frequency, and duration of the training interventions, although all included content consistent with the five-domains of the CHIME model. All interventions used direct, in-person teaching, and prioritised interactive, experiential learning, however a number were limited by the absence of feedback, the use of one-off, rather than repeated/follow-up sessions, and a reliance on classroom-based, rather than in-vivo, training. There was limited evidence to suggest a consistent effect of training on staff or service user outcomes, and there was no clear association between the delivery and design characteristics of the interventions and reported outcomes. In considering the development of recovery training for supported accommodation staff, little guidance can be taken from the reviewed literature. Any training package must be developed with consideration of the unique contextual and organisational characteristics of these services. The authors recommend viewing training as one component of a broader goal of service transformation.

Recovery in Supported Accommodations: A Scoping Review and Synthesis of Interventions for People with Severe Mental Illness

Research on the recovery domains beside clinical recovery of people with severe mental illness in need of supported accommodations is limited. The aim of this study was (1) to investigate which recovery interventions exist for this group of people and (2) to explore the scientific evidence. We conducted a scoping review, including studies with different designs, evaluating the effectiveness the recovery interventions available. The search resulted in 53 eligible articles of which 22 focused on societal recovery, six on personal recovery, five on functional recovery, 13 on lifestyle-interventions, and seven on creative and spiritual interventions. About a quarter of these interventions showed added value and half of them initial promising results. The research in this area is still limited, but a number of recovery promoting interventions on other areas than clinical recovery have been developed and evaluated. Further innovation and research to strengthen and repeat the evidence are needed.

Development and evaluation of a strength-based method to promote employment of work-disability benefit recipients with multiple problems: a feasibility study

Background

For people with disabilities, chances to find or keep work are negatively affected by multiple problems like lower education, poverty and poor health. Furthermore, although active labour market policies proved to be effective for unemployed in general, success rates are poor for persons who are unemployed due to multiple problems. The present study aims to describe the development of a method as well as professional training to teach its application, and to assess the feasibility of method and training. The Strength-based method (CARm) aims to promote employment of work-disability benefit recipients with multiple problems.

Methods

The main principles of the Strength model were redesigned for better applicability in a population of work-disability beneficiaries, resulting in the CARm method. As part of the CARm method, a training module for Labour Experts (LEs) was developed. To assess the new designed method and training, a one-group, pre-post design was used. Data were collected from eight participating LEs, five female and 3 male, aged between 41and 55 years and having 2–17 years working experience. We used self-report questionnaires and a semi-structured discussion meeting after the training sessions with the LEs.

Results

Eight labour experts (LEs) from the Dutch Social Security Institute participated in the study. Most LEs felt an improvement in their ability to ascertain developmental needs, opportunities and threats in the client’s situation. Three months after the training, LEs almost unanimously agreed on the statements ‘I expect to use the CARm method more frequently in the future’ and ‘I use the CARm method in daily practice whenever possible’. The overall rating for the training on a scale from 1 to 10 was 7.6 (range 7–9). The overall satisfaction with the trainers was good.

Conclusions

The CARm method and training was found to be a feasible approach to facilitate LEs working at the UWV reintegration service to support clients with multiple problems. Sufficient managerial support for participating LEs is a key factor for successful implementation of CARm. Results show that CARm is worth testing for efficacy in a future trial.

IPS in Supported Housing: Fidelity and Employment Outcomes Over a 4 Year Period

Background: People with severe mental illness have difficulties finding and maintaining competitive employment. This is particularly so for those living in supported housing who, by definition, have significant day-to-day support needs: in the Netherlands only 3 to 5% of people with serious mental health problems who live in supported housing are competitively employed. To support these people in finding and maintaining competitive employment, Individual Placement, and Support (IPS) was introduced within supported housing services in the Netherlands in 2015. As this is the first country that broadly implemented IPS in supported housing settings, this paper will focus on the first results regarding feasibility and effects on employment in clients of IPS in this sector. Methods: We investigated the feasibility and employment outcomes of delivering IPS in supported housing services using fidelity assessments and quarterly employment outcomes on IPS program level within eight supported housing organizations, and compared these with 21 mental health treatment organizations in the Netherlands over a 4 year period. We investigated possible reasons for our findings and their implications through qualitative evaluations of the IPS fidelity assessors' notes and additional focus groups with IPS specialists and coordinators from supported housing services and fidelity assessors. Results: The overall fidelity scores indicated reasonable implementation of the IPS model within both supported housing services and mental health services. However, there were differences between services with regard to specific fidelity items; mental health treatment organizations scored higher for team integration, whereas supported housing services scored higher for rapid job search and caseload size, diversity of jobs, and employers. Our qualitative data suggested that the difference in team integration between the two sectors was due to differences in their organizational and financial structures, as well as in the specific needs of their clients. Conversely, supported housing services had better connections with employers which facilitated more rapid job searching and greater diversity in employment opportunities. The average total client employment rate did not significantly differ; and was 25.8% per quarter in supported housing services and 29.6% in mental health treatment services. Conclusion: Implementing IPS in supported housing settings is both feasible and effective.

Contemporary approaches in mental health rehabilitation

In many European countries, deinstitutionalisation has been an ongoing process over the last few decades. Mental health organisations were transformed to provide support in a more integrated and comprehensive manner, preferably in their own homes in the community. Yet, despite the welcome aspiration of community integration for all, people with complex mental health problems (also termed severe mental illness) have continued to require high levels of support, in inpatient settings and in the community. This group's needs make them highly dependent on their caregivers. The attitudes, knowledge and skills of the staff providing treatment and support is crucial to their recovery. Rehabilitation programmes provide a much-needed framework to guide practitioners and help them organise and focus their recovery-oriented approach. In this editorial, we will provide a non-exhaustive overview of such rehabilitation programmes and interventions to illuminate the wide scope and practical usability of these interventions for this group of people with complex mental health problems.

Training professionals in a recovery-oriented methodology: a mixed method evaluation

BACKGROUND

Several studies have reported difficulties concerning the implementation of recovery-oriented interventions. In this study, the effect of training in the Comprehensive Approach to Rehabilitation (CARe) on daily practice was evaluated. Additionally, we aimed to acquire insight into the experiences with the implementation process involving professionals, management and trainers.

METHODS

Fourteen teams for sheltered and supported housing in the Netherlands participated in this study. As part of a cluster-randomised controlled trial (RCT) design, eight teams received training in the CARe methodology. Model fidelity (using the CARe fidelity audit) and professionals' knowledge of recovery (using the Recovery Knowledge Inventory) were measured for all teams until 20 months after the start. Afterwards, an evaluation meeting with participating stakeholders was organised in which barriers and facilitators of the implementation of the CARe methodology were inventoried.

RESULTS

Ten months after the training, the intervention teams scored higher than the control teams on the fidelity subscales: 'recovery', 'strengths orientation' and 'amount of training and coaching'. Twenty months after the training, only the effect of 'amount of coaching and training' remained. Additionally, 'methodological working' clearly differed between the groups after 20 months in favour of the intervention teams. In all teams, model fidelity was moderate at both measurements. The knowledge of recovery of the trained teams was slightly and significantly higher at 10 and 20 months after training. Although professionals were positive about recovery and strength-oriented working, they experienced several organisational and societal barriers.

CONCLUSION

Training in the CARe methodology improved the fidelity and knowledge of recovery among professionals. However, the differences were small, and fidelity decreased over time. More in-depth knowledge is needed on which barriers professionals experience in practice so that tailored training and implementation strategies can be developed. Furthermore, more attention is needed for professional development and the translation of theory into practice.

The Importance of Nidotherapy and Environmental Change in the Management of People with Complex Mental Disorders

Much has been done in the last 50 years to achieve a better understanding of the psychosocial causes and other factors influencing the manifestation of mental illness, but there has been a conspicuous omission. Although gross environmental deficiencies were exposed in old mental institutions, 70 years ago the more subtle maladaptive settings that reinforce chronicity in mental illness have often been forgotten. In this review, the potential of systematic environmental manipulation as a treatment (nidotherapy) and other similar forms of management, used many times in the past but now mainly in forensic settings, is examined. There is now accumulating evidence, reinforced by controlled trials, that planned environmental change, preferably carried out with the full cooperation of the patient, can be a major contributor to therapeutic benefit. It is also very cost-effective. All forms of the environment, physical, social and personal, can be addressed in making assessments, and once a planned way forward has been chosen, progress can be monitored by personnel with limited mental health experience. These interventions have applications in general mental health and occupational health services and deserve much wider use.