Rob Whitley

Social capital and mental health

Evidence for inequalities in morbidity and mortality by occupational social class and material standard of living has become irrefutable ([Acheson, 1998][1]). Attention has now turned to the effects of social context ([MacIntyre et al , 1993][2]; [MacIntyre, 1997][3]; [Ecob & MacIntyre, 2000][4]; [

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

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

Fidelity Outcomes in the National Implementing Evidence-Based Practices Project

OBJECTIVE This article presents fidelity outcomes for five evidence-based practices that were implemented in routine public mental health settings in the National Implementing Evidence-Based Practices Project. METHODS Over a two-year period 53 community mental health centers across eight states implemented one of five evidence-based practices: supported employment, assertive community treatment, integrated dual disorders treatment, family psychoeducation, and illness management and recovery. An intervention model of practice dissemination guided the implementation. Each site used both human resources (consultant-trainers) and material resource (toolkits) to aid practice implementation and to facilitate organizational changes. External assessors rated fidelity to the evidence-based practice model every six months from baseline to two years. RESULTS More than half of the sites (29 of 53, or 55%) showed high-fidelity implementation at the end of two years. Significant differences in fidelity emerged by evidence-based practice. Supported employment and assertive community treatment had higher fidelity scores at baseline and across time. Illness management and recovery and integrated dual disorders treatment had lower scores on average throughout. In general, evidence-based practices showed an increase in fidelity from baseline to 12 months, with scores leveling off between 12 and 24 months. CONCLUSIONS Most mental health centers implemented these evidence-based practices with moderate to high fidelity. The critical time period for implementation was approximately 12 months, after which few gains were made, although sites sustained their attained levels of evidence-based practice fidelity for another year.

Social capital and psychiatry: Review of the literature

&NA; Social capital is an umbrella term used to describe aspects of social networks, relations, trust, and power, as a function of either the individual or a geographical entity (e.g., a city neighborhood). Increased attention is being paid to the role that social capital can play in determining a variety of physical health outcomes, though less attention has been paid to its role in determining mental health outcomes. This relative inattention continues despite a long historical tradition in psychiatry of exploring the role that socio‐environmental factors can play in the etiology and course of mental illness. In this review, we begin by tracing the historical development of the concept of social capital, describing and analyzing competing definitions. We then proceed to review the published studies that examine the relationship between social capital and mental health—looking first at studies that focus on depression and anxiety, and second at studies that focus on psychoses. After briefly exploring whether social capital can have a detrimental effect on mental health, we discuss how knowledge regarding social capital may aid the clinician and mental health services. We go on to make a number of suggestions relevant to methodological, theoretical, and empirical advancement. These suggestions include refining the definitions of social capital, paying attention to communities without propinquity, and constructing contextual indicators of social capital. We conclude by remarking that social capital may be a promising heuristic for studies in community psychiatry and may even help individual clinicians in designing treatment plans. Despite all this promise, however, there is a lack of strong evidence supporting the hypothesis that social capital protects mental health.

Qualitative research in psychiatry.

This paper is an overview of qualitative research and its application to psychiatry. It is introductory and attempts to describe both the aims of qualitative research and its underlying philosophical basis. We describe the practice and process of qualitative research and follow this with an overview of the 3 main methods of inquiry: interviews, focus groups, and participant observation. Throughout the paper, we offer examples of cases where qualitative research has illuminated, or has the potential to illuminate, important questions in psychiatric research. We describe methods of sampling and follow with an overview of qualitative analysis, appropriate checks on rigour, and the presentation of qualitative results. The paper concludes by arguing that qualitative methods may be an increasingly appropriate methodology to answer some of the demanding research questions being posed in 21st century psychiatry.

Recovery: A Dimensional Approach

Various definitions, dimensions, and components of recovery have been posited. Building on existing work, the authors propose five superordinate dimensions of recovery: clinical recovery, experiencing improvements in symptoms; existential recovery, having a sense of hope, empowerment, agency, and spiritual well-being; functional recovery, obtaining and maintaining valued societal roles and responsibilities, including employment, education, and stable housing; physical recovery, pursuing better health and a healthy lifestyle; and social recovery, experiencing enhanced and meaningful relationships and integration with family, friends, and the wider community. The model also identifies lay, professional, and systemic resources that promote each recovery dimension.

The Role of Staff Turnover in the Implementation of Evidence-Based Practices in Mental Health Care

OBJECTIVES This study examined turnover rates of teams implementing psychosocial evidence-based practices in public-sector mental health settings. It also explored the relationship between turnover and implementation outcomes in an effort to understand whether practitioner perspectives on turnover are related to implementation outcomes. METHODS Team turnover was measured for 42 implementing teams participating in a national demonstration project examining implementation of five evidence-based practices between 2002 and 2005. Regression techniques were used to analyze the effects of team turnover on penetration and fidelity. Qualitative data collected throughout the project were blended with the quantitative data to examine the significance of team turnover to those attempting to implement the practices. RESULTS High team turnover was common (M+/-SD=81%+/-46%) and did not vary by practice. The 24-month turnover rate was inversely related to fidelity scores at 24 months (N=40, beta=-.005, p=.01). A negative trend was observed for penetration. Further analysis indicated that 71% of teams noted that turnover was a relevant factor in implementation. CONCLUSIONS The behavioral health workforce remains in flux. High turnover most often had a negative impact on implementation, although some teams were able to use strategies to improve implementation through turnover. Implementation models must consider turbulent behavioral health workforce conditions.

Implementation of Integrated Dual Disorders Treatment: A Qualitative Analysis of Facilitators and Barriers

OBJECTIVE Approximately half of the people who have serious mental illnesses experience a co-occurring substance use disorder at some point in their lifetime. Integrated dual disorders treatment, a program to treat persons with co-occurring disorders, improves outcomes but is not widely available in public mental health settings. This report describes the extent to which this intervention was implemented by 11 community mental health centers participating in a large study of practice implementation. Facilitators and barriers to implementation are described. METHODS Trained implementation monitors conducted regular site visits over two years. During visits, monitors interviewed key informants, conducted ethnographic observations of implementation efforts, and assessed fidelity to the practice model. These data were coded and used as a basis for detailed site reports summarizing implementation processes. The authors reviewed the reports and distilled the three top facilitators and barriers for each site. The most prominent cross-site facilitators and barriers were identified. RESULTS Two sites reached high fidelity, six sites reached moderate fidelity, and three sites remained at low fidelity over the two years. Prominent facilitators and barriers to implementation with moderate to high fidelity were administrative leadership, consultation and training, supervisor mastery and supervision, chronic staff turnover, and finances. CONCLUSIONS Common facilitators and barriers to implementation of integrated dual disorders treatment emerged across sites. The results confirmed the importance of the use of the consultant-trainer in the model of implementation, as well as the need for intensive activities at multiple levels to facilitate implementation. Further research on service implementation is needed, including but not limited to clarifying strategies to overcome barriers.

Recovery and severe mental illness: description and analysis.

The notion of recovery has been embraced by key stakeholders across Canada and elsewhere. This has led to a proliferation of definitions, models, and research on recovery, making it vitally important to examine the data to disentangle the evidence from the rhetoric. In this paper, first we ask, what do people living with severe mental illness (SMI) say about recovery in autobiographical accounts? Second, what do they say about recovery in qualitative studies? Third, from what we have uncovered about recovery, can we learn anything from quantitative studies about proportions of people leading lives of recovery? Finally, can we identify interventions and approaches that may be consistent or inconsistent with the grounded notions of recovery unearthed in this paper? We found that people with mental illness frequently state that recovery is a journey, characterized by a growing sense of agency and autonomy, as well as greater participation in normative activities, such as employment, education, and community life. However, the evidence suggests that most people with SMI still live in a manner inconsistent with recovery; for example, their unemployment rate is over 80%, and they are disproportionately vulnerable to homelessness, stigma, and victimization. Research stemming from rehabilitation science suggests that recovery can be enhanced by various evidence-based services, such as supported employment, as well as by clinical approaches, such as shared decision making and peer support. But these are not routinely available. As such, significant systemic changes are necessary to truly create a recovery-oriented mental health system.

Strategies for Improving Fidelity in the National Evidence-Based Practices Project

Background: The National Evidence-Based Practices (EBPs) Project developed and tested a model for facilitating the implementation of five psychosocial EBPs for adults with severe mental illness in the United States. Methods: The implementation model was tested in 53 sites in 8 states. In each site, one of the five EBPs was adopted for implementation and then studied for a 2-year period using a combination of qualitative and quantitative methods. Findings: At baseline, none of the sites had programs attaining high fidelity. Four factors were identified as influencing fidelity: (a) EBP-specific factors, (b) governmental factors, (c) leadership factors, and (d) fidelity review factors. Conclusion: A multipronged implementation strategy was effective in achieving high fidelity in over half of the sites seeking to implement a new EBP.