Maria Monroe-DeVita

Burnout in Mental Health Services: A Review of the Problem and Its Remediation

Staff burnout is increasingly viewed as a concern in the mental health field. In this article we first examine the extent to which burnout is a problem for mental health services in terms of two critical issues: its prevalence and its association with a range of undesirable outcomes for staff, organizations, and consumers. We subsequently provide a comprehensive review of the limited research attempting to remediate burnout among mental health staff. We conclude with recommendations for the development and rigorous testing of intervention approaches to address this critical area.

The TMACT: A New Tool for Measuring Fidelity to Assertive Community Treatment

BACKGROUND: Fidelity assessment is important for implementation of evidence-based practices (EBPs), including assertive community treatment (ACT). OBJECTIVES: The TMACT, an enhanced fidelity tool, was developed and pilot-tested to better assess critical ACT structures and processes. DESIGN: Ten ACT teams were administered the TMACT and the long-standing ACT fidelity measure, the Dartmouth Assertive Community Treatment Scale (DACTS), at baseline, 6, 12, and 18 months. RESULTS: Overall, fidelity scores for all 10 teams were relatively high. Six teams showed improvement, concluding with high TMACT scores at 18 months. Four teams with significantly lower total scores had experienced turnover and organizational barriers. TMACT ratings were higher in core ACT practices than in recovery practices and EBPs. TMACT scores rose steadily but were significantly lower than DACTS scores, which remained unchanged. CONCLUSIONS: The TMACT sets higher performance standards through enhanced assessment of recovery-orientation, EBPs, and teamwork and is more sensitive to change than the DACTS.

Fidelity to Recovery-Oriented ACT Practices and Consumer Outcomes

OBJECTIVE A previous study of a recovery-oriented assertive community treatment initiative (PACT) in Washington State found reductions in state psychiatric hospital use and related costs for PACT participants, especially in the first six months after enrollment and for consumers who were high users of the state psychiatric hospital before ACT enrollment. This study examined whether these outcomes varied by team fidelity to recovery-oriented ACT practices. METHODS Generalized estimating equations (GEE) were used to examine the relationship between scores on the Tool for Measurement of Assertive Community Treatment (TMACT), a recently developed tool for assessing fidelity to recovery-oriented ACT, and the use of state hospitals, local hospitals, emergency departments, local crisis stabilization units, and arrests for 631 PACT consumers. These relationships were also examined for PACT consumers with any state hospital use (N=450) and those considered high users of the state hospital (≥ 96 days in two years before PACT enrollment). RESULTS TMACT scores were associated (p<.01) with a decrease in the amount of use but not the probability of using state psychiatric hospitals, local hospital psychiatric inpatient units, and local crisis stabilization units. The marginal effects of higher TMACT scores on the probability and use of emergency departments or arrests were not statistically significant. CONCLUSIONS This study provides preliminary evidence for the predictive validity of the TMACT. Future research should examine the subscale structure of the TMACT as well as the association between TMACT fidelity and consumer well-being, quality of life, and other important person-centered outcomes.

Comparative Effectiveness of a Burnout Reduction Intervention for Behavioral Health Providers

OBJECTIVES Prior research found preliminary effectiveness for Burnout Reduction: Enhanced Awareness, Tools, Handouts, and Education (BREATHE), a daylong workshop for reducing burnout among behavioral health providers. Using a longer follow-up compared with prior research, this study compared the effectiveness of BREATHE and a control condition. METHODS Behavioral health providers (N=145) from three U.S. Department of Veterans Affairs facilities and two social service agencies were randomly assigned to BREATHE or person-centered treatment planning. Burnout and other outcomes were compared across groups over time. RESULTS Analyses yielded no significant differences between groups. However, BREATHE participants showed small but statistically significant improvements in cynicism (six weeks) and in emotional exhaustion and positive expectations for clients (six months). Participants in the control condition showed no significant changes over time. CONCLUSIONS Although it did not demonstrate comparative effectiveness versus a control condition, BREATHE could be strengthened and targeted toward both distressed providers and their organizations.

ACT and Recovery: What We Know About Their Compatibility

While assertive community treatment (ACT) is a widely implemented evidence-based practice, the extent of its recovery orientation has been debated. A literature search identified 16 empirical articles studying recovery and ACT. These 16 studies were classified as involving stakeholder perceptions, interventions, or fidelity measurement. Stakeholders generally viewed ACT as being recovery oriented; research on both interventions and fidelity measurement showed promising approaches. Overall the literature yielded encouraging findings regarding ACT and recovery, though there remains a dearth of research on the topic. We discuss future directions for research and practice to ensure that ACT programs skillfully support recovery.

Evaluating Integrated Treatment Within Assertive Community Treatment Programs: A New Measure

Assertive community treatment (ACT) is an evidence-based practice that consists of a multidisciplinary team of professionals who provide intensive and comprehensive services to people with serious mental disorders living in the community. ACT has been shown to be effective in reducing hospital days and increasing housing stability for service recipients. However, more than half of the people in these programs typically have a co-occurring substance use disorder, and evidence for the models effectiveness in treating dual disorders is less consistent. One reason cited for this shortcoming is the apparent failure to provide care consistent with the principles and practices of integrated dual disorders treatment, itself an evidence-based practice with demonstrated effectiveness. This is a problem of treatment fidelity, one that is addressed in a new ACT fidelity measure, the Tool for Measurement of Assertive Community Treatment (TMACT), which assesses not only the structural features of ACT but also the quality of clinical processes and services. With the TMACT, evaluators assess particular aspects of staff roles and team functioning as well as integration of critical elements of other evidence-based services, including integrated dual disorders treatment and recovery-oriented, person-centered practices. The measure is described, with particular detail provided for items that assess integrated dual disorders treatment, and a case example is presented to illustrate how the TMACT is used to guide consultation for ensuring effective integrated dual disorders treatment implementation within ACT.

Development and Evaluation of a Fidelity Instrument for PEARLS.

Purpose This manuscript describes the development and the preliminary evaluation of a fidelity instrument for the Program for Encouraging Active and Rewarding Lives (PEARLS), an evidence-based depression care management (DCM) program. The objective of the study was to find an effective, practical, multidimensional approach to measure fidelity of PEARLS programs to the original, research-driven PEARLS protocol in order to inform program implementation at various settings nationwide. Methods We conducted key informant interviews with PEARLS stakeholders, and held focus groups with former PEARLS clients, to identify core program components. These components were then ranked using a Q-sort process, and incorporated into a brief instrument. We tested the instrument at two time points with PEARLS counselors, other DCM program counselors, and non-DCM program counselors (n = 56) in six states. Known-groups method was used to compare findings from PEARLS programs, other DCM programs, and non-DCM programs. We asked supervisors of the counselors to complete the fidelity instrument on behalf of their counselors to affirm the validity of the results. We examined the association of PEARLS program fidelity with individual client outcomes. Results Program for Encouraging Active and Rewarding Lives providers reported the highest fidelity scores compared to DCM program providers and non-DCM program providers. The sample size was too small to yield significant results on the comparison between counselor experience and fidelity. Scores varied between PEARLS counselors and their supervisors. PEARLS program fidelity was not significantly correlated with client outcomes, suggesting that other implementation factors may have influenced the outcomes and/or that the instrument needs refinement. Conclusion Our findings suggest that providers may be able to use the instrument to assess PEARLS program fidelity in various settings across the country. However, more rigorous research is needed to evaluate instrument effectiveness.

Social capital and burnout among mental healthcare providers

Abstract Background: Provider burnout is a critical problem in mental health services. Contributing factors have been explicated across three domains: personal, job and organizational characteristics. Of these, organizational characteristics, including workplace environment, appear to be particularly important given that most interventions addressing burnout via the other domains (e.g. bolstering personal coping skills) have been modestly effective at best. Aims: This study builds on previous research by using social capital as a framework for the experience of work social milieu, and aims to provide a richer understanding of how workplace social environment might impact burnout and help create more effective ways to reduce burnout. Methods: Providers (n = 40) taking part in a larger burnout intervention study were randomly selected to take part in interviews regarding their workplace environment and burnout. Participant responses were analyzed thematically. Results: Workplace social milieu revolved around two primary themes: workplace social capital in provider burnout and the protective qualities of social capital in cohesive work teams that appear to mitigate burnout. Conclusions: These results imply that work environments where managers support collaboration and social interaction among work teams may reduce burnout.

Impact of tobacco, alcohol and cannabis use on treatment outcomes among patients experiencing first episode psychosis: Data from the national RAISE‐ETP study

The primary aim of this study was to examine the effect of recent tobacco, alcohol and cannabis use on treatment outcomes among participants experiencing first episode psychosis (FEP).

Established and emerging elements in the TMACT: Measuring fidelity to an evolving model

We thank Professor McGrew for his thoughtful comments on several important issues around fidelity to assertive community treatment (ACT; McGrew, 2011). We appreciate the favorable comments he does make about the Tool for Measurement of Assertive Community Treatment (TMACT; Monroe-DeVita, Teague, & Moser, 2011), as well as the opportunity to respond to his more predominant concerns. Below we offer alternative perspectives to his assumptions in three main areas: (a) the nature of ACT; (b) the sources of admissible evidence in the development of fidelity measures; and (c) the nature of fidelity measures themselves. We entirely acknowledge at the outset the accuracy of his point that important content in many of the TMACT items has not yet been rigorously evaluated and has been incorporated on a hypothetical basis. But we argue that this is consistent with precedent for fidelity measurement in general and is needed at this point for fidelity measurement of ACT in particular. To begin, we believe that McGrew offers too narrow a view of ACT, distinguishing between “traditional ACT elements” and other services addressed in the TMACT. These traditional ACT elements would appear to consist primarily of basic structures and procedures, with little specification of the services and working processes of the model itself. It may be that we share with him the notion of ACT as an organizing framework or platform for a broad range of services to be delivered. If so, however, McGrew’s view would limit ACT to little more than that platform; ours would include much more of what the platform is intended to support (i.e., specific team processes and services). The more limited conception of ACT potentially ignores a fundamental charge of the model: to be the first-line, if not sole, provider of all the services that ACT consumers need. Implicit in this charge is the requirement to provide these services with optimal effectiveness, thereby requiring ACT clinicians to keep pace with two significant types of changes since the first implementation of ACT in the 1970s and especially in the years since the initial appearance of the Dartmouth Assertive Community Treatment Scale (DACTS; Teague, Bond, & Drake, 1998). First, the field’s concept of what goals and outcomes are possible and desired by ACT consumers has evolved. Early on, there was much greater emphasis on substantially slowing the revolving hospital door; now we are more focused on helping consumers become more active in their communities, obtaining competitive employment, and improving self-sufficiency so that dependence on ACT and other professional services gradually decreases, all inherent in the concept of recovery (Drake & Deegan, 2008; Salyers & Tsemberis, 2007). Another important change in the field entails more knowledge about how best to help consumers achieve these kinds of goals—in particular, the growing body of evidence for what kinds of practices clinicians serving this population should employ. Neither the technology of evidence-based practices (EBPs) nor the vision of recovery were known and embraced in the early years of development and dissemination of ACT, but the model was nonetheless defined in terms of providing the best possible practice of the day. The view of ACT offered through the TMACT is a contemporary update. By including to the degree possible both a recovery orientation and what we have learned about effective rehabilitative practices, teams fulfill rather than exceed the fundamental nature of ACT. Readers should also be clear, however, that wholesale incorporation of EBPs is not necessarily called for, though there is some evidence that this may be possible (Salyers et al., 2010). The TMACT does not operationalize an expectation that ACT providers will fully meet the criteria for EBPs as separately defined and measured with their own full fidelity scales. Instead, the TMACT incorporates just one to three items for each specialty area to assess whether teams include qualified specialists who apply the general tenets of these practices along with their more generalist practices and at the same time support their colleagues in learning to do likewise. Second, we hold a different set of assumptions concerning the types and sources for evidence used to specify and measure ACT. McGrew argues for including only items tapping program elements rigorously demonstrated to have contributed to outcome. Although this experimental 396086 JAP17110.1177/1078390310396086Monr oe-DeVita et al.Journal of the American Psychiatric Nurses Association