William A. Anthony

Implementing recovery oriented evidence based programs: identifying the critical dimensions.

In the decades of the 1990s many mental health programs and the systems that fund these programs have identified themselves as recovery-oriented. A program that is grounded in a vision of recovery is based on the notion that a majority of people can grow beyond the catastrophe of a severe mental illness and lead a meaningful life in their own community. First person accounts of recovery and empirical research have led to a developing consensus about the service delivery values underlying recovery. The emphasis on recovery-oriented programming has been concurrent with a focus in the field on evidence-based practices. We propose that evidence based practices be implemented in a manner that is recovery compatible. Program dimensions for evidence based practice, such as program mission, policies, procedures, record keeping and staffing should be consistent with recovery values in order for a program to be considered to be recovery-oriented. This article describes the critical dimensions of such value based practice, regardless of the service the recovery oriented mental health programs provide (e.g., treatment, case management, rehabilitation). The aim of this first attempt at conceptualizing recovery-oriented mental health programs is to both provide direction to those involved in program implementation of evidence based mental health practices, as well as providing a stimulus for further discussion in the field.

The process of recovery from schizophrenia

To facilitate future research on recovery from schizophrenia a qualitative, longitudinal analysis was conducted with individuals participating in rehabilitation to identify themes associated with improvement in functioning and subjective experience. Twelve individuals with a diagnosis of schizophrenia or schizoaffective disorder were randomly selected from a just concluded two-year study of psychiatric rehabilitation. Each individual was followed for an additional four years. Every four to eight months each person participated in a semistructured,audiotaped interview about his or her current life experiences. Tapes were evaluated independently by three assessors for themes and phases that emerged from these life experiences. The qualitative analysis characterized the process of recovery as having phases, dimensions, indicators, and barriers to recovery. This empirically derived description of the process of recovery, from the perspective of people who are experiencing it, can be used to generate research hypotheses for future studies to further our understanding and to promote recovery from schizophrenia.

Research on Evidence-Based Practices: Future Directions in an Era of Recovery

Many mental health systems are trying to promote the adoption of what has come to be known as evidence-based practices while incorporating a recovery vision into the services they provide. Unfortunately, much of the existing, published, research on evidence-based practices was conceived without an understanding of the recovery vision and/or implemented prior to the emergence of the recovery vision. As result, evidence-based practice research that has been published to date is deficient in speaking to a system being built on a recovery philosophy and mission; these deficiencies are detailed, and suggestions are advanced for new directions in evidence-based practice research.

Serving street-dwelling individuals with psychiatric disabilities: outcomes of a psychiatric rehabilitation clinical trial.

OBJECTIVES This study tested a psychiatric rehabilitation approach for organizing and delivering services to street-dwelling persons with severe mental illness. METHODS Street-dwelling persons with severe mental illness were randomly assigned to the experimental program (called Choices) or to standard treatment in New York City. We assessed study participants at baseline and at 6-month intervals over 24 months, using measures of service use, quality of life, health, mental health, and social psychological status. The average deviation from baseline summary statistic was employed to assess change. RESULTS Compared with persons in standard treatment (n = 77), members of the experimental group (n = 91) were more likely to attend a day program (53% vs 27%), had less difficulty in meeting their basic needs, spent less time on the streets (55% vs 28% reduction), and spent more time in community housing (21% vs 9% increase). They showed greater improvement in life satisfaction and experienced a greater reduction in psychiatric symptoms. CONCLUSIONS With an appropriate service model, it is possible to engage disaffiliated populations, expand their use of human services, and improve their housing conditions, quality of life, and mental health status.

The Nature and Dimensions of Social Support Among Individuals with Severe Mental Illnesses

Recent research suggests that social support is associated with recovery from chronic diseases, greater life satisfaction, and enhanced ability to cope with life stressors. To further research in the area of social support and serious psychiatric disabilities, more reliable and valid measures are needed to assess this construct. The purpose of this study was to assess the psychometric properties of a widely used measure of social support (the Interpersonal Support Evaluation Checklist) among people with severe mental illness. We collected data on the ISELs relationship to quality of life, self-esteem, psychiatric symptoms and vocational status among 147 participants. Factor and reliability analyses, as well as correlational analyses were undertaken. We found evidence for the reliability and validity of the ISEL when used with persons with severe mental illness. Taken together, our findings suggested that self-esteem, quality of life, and psychiatric symptoms were able to predict 38% of the variance in perceived social support. More favorable social supports increased the odds of being employed at 9months into the study and social support was predictive of experiencing fewer psychiatric symptoms. Some forms of social support were perceived less favorably with age, but no other demographic or clinical variables significantly predicted perceived social supports.

Evidence-based practices: Setting the context and responding to concerns.

After nearly 20 years of progress in general medicine, the evidence-based practice movement is becoming the central theme for mental health care reform in the first decade of 2000. Several leaders in the movement met to discuss concerns raised by six stakeholder groups: consumers, family members, practitioners, administrators, policy makers, and researchers. Recurrent themes relate to concerns regarding the limits of science, diversion of funding from valued practices, increased costs, feasibility, prior investments in other practices, and shifts in power and control. The authors recommend that all stakeholder groups be involved in further dialog and planning to ensure that practices emerge that represent the integration of the best research evidence with clinical expertise and consumer values.

Recovery: a common vision for the fields of mental health and addictions.

The vision of recovery is reshaping the fields of mental health and addiction services. This paper reviews how this broad vision is shaping common goals, principles, values and strategies across the two fields. We further examine how a common vision of recovery can positively impact the treatment of co-occurring disorders and speculate on how this vision can bridge the seeming differences between these two fields and reshape a mutual understanding of the essentials of recovery from severe mental illness and addiction.

Prediction of vocational outcome based on clinical and demographic indicators among vocationally ready clients.

This study examined the clinical and demographic correlates of work skills and vocational outcome for persons with psychiatric disabilities. The same clinical, demographic, work skills, and vocational outcome instruments were administered to 275 persons working toward their vocational goals at three psychosocial rehabilitation centers. Data regarding vocational outcomes were collected quarterly over a period of 3 1/4 years. Using multivariate statistical techniques, clinical and demographic variables that predict work skills and future vocational outcomes were identified. The implications of the findings for program administrators, system planners, and researchers are discussed.

Eliminating Seclusion and Restraint in Recovery-Oriented Crisis Services

The use of seclusion and physical restraint is viewed as a practice incompatible with the vision of recovery, and its therapeutic benefit remains unsubstantiated. This Open Forum describes an initiative that began in 1999 at two crisis centers that was designed to completely eliminate the practice of seclusion and restraint. Seclusion and restraint elimination strategies included strong leadership direction, policy and procedural change, staff training, consumer debriefing, and regular feedback on progress. Existing records indicated that over a 58-month follow-up period (January 2000 to October 2004), the larger crisis center took ten months until a month registered zero seclusions and 31 months until a month recorded zero restraints. The smaller crisis center achieved these same goals in two months and 15 months, respectively. The success of this initiative suggests that policy makers and organizational leaders familiarize themselves with these and other similar seclusion and restraint reduction strategies that now exist.

Unique Issues in Assessing Work Function Among Individuals with Psychiatric Disabilities

With the admission of people who experience psychiatric disabilities in the state–federal vocational rehabilitation system and the Social Security disability rolls in the 1960s, assessment of their capacity to work has been a major concern. Given the rising rates of claims for psychiatric disability in both the public and the private sectors, and the disappointing employment outcomes of people with psychiatric disabilities compared to those with other disabilities, there have been numerous initiatives to accurately assess their employment potential. Historically, such assessment within the Social Security Administration has relied upon evaluation of a persons medical impairment, but numerous studies suggest a weak relationship between measures of psychiatric diagnosis or symptoms and work outcome. Efforts have been undertaken to identify valid and reliable methods of assessing the ability of people with psychiatric disabilities to work. The authors review (a) methods of assessing work function for this population, and (b) the literature on predictors of work functioning and the nature of psychiatric disability, and suggest implications for disability determination policies and for future research.