Barriers to Meaningful Participatory Mental Health Services Research and Priority Next Steps: Findings From a National Survey.

OBJECTIVE: A growing consensus has emerged regarding the importance of stakeholder involvement in mental health services research. To identify barriers to and the extent of stakeholder involvement in participatory research, the authors undertook a mixed-methods study of researchers and community members who reported participation in such research. METHODS: Eight consultative focus groups were conducted with diverse groups of stakeholders in mental health services research (N=51 unique participants, mostly service users), followed by a survey of service users, family members, community providers, and researchers (N=98) with participatory research experience. Focus groups helped identify facilitators and barriers to meaningful research collaboration, which were operationalized in the national survey. Participants were also asked about high-priority next steps. RESULTS: The barrier most strongly endorsed as a large or very large problem in the field was lack of funding for stakeholder-led mental health services research (76%), followed by lack of researcher training in participatory methods (74%) and insufficiently diverse backgrounds among stakeholders (69%). The two most frequently identified high-priority next steps were ensuring training and continuing education for researchers and stakeholders (33%) and authentically centering lived experience and reducing tokenism in research (26%). CONCLUSIONS: These findings suggest a need for increased attention to and investment in the development, implementation, and sustainment of participatory methods that prioritize collaboration with direct stakeholders, particularly service users, in U.S. mental health services research. The findings also underscore the presence and potentially important role of researchers who dually identify as service users and actively contribute a broader orientation from the service user-survivor movement.

Self-reliance and belonging: Guest experiences of a peer respite.

Objective: A peer respite is a voluntary, short-term, overnight program that provides community-based mutual support to people experiencing a mental health crisis. This qualitative study of guest experiences at 1 peer respite examines its role in fostering recovery and wellbeing. Method: Conventional content analysis of interviews with 20 peer respite guests resulted in a thematic framework containing 7 "clusters" of themes with related subthemes. Results: The following themes emerged from the analysis and include both positive and negative experiences: belongingness, confidence and hope, crisis self-management, experiencing mutual support, freedom and responsibility, linking to community, and conflict and confrontation. Some guests endorsed the peer respite as a temporary break from stressful life situations, a homelike space for mutual support and community, and a preferred alternative to traditional crisis services. Others struggled with the unstructured environment and expectations for shared responsibility and self-reliance. Conclusions and Implications for Practice: Peer respites strengthen self-reliance and social connectedness and offer a viable alternative to traditional crisis services for some people some of the time. The results suggest potential "key ingredients" for peer respites, including a homelike environment, voluntary and self-determined supports, and peer support staff who possess the capacity for developing healing and genuine connections with guests while also promoting shared responsibility and self-reliance. Future research should further develop this theory of change and establish peer respite fidelity criteria based on program elements that seem to contribute to positive outcomes. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Self-direction and the Social Determinants of Health.

Social determinants of health-defined by the World Health Organization as "the social factors and physical conditions of the environment in which people are born, live, learn, play, work, and age"-are increasingly discussed as having relevance in community mental health service systems. This brief report describes how self-direction-an approach in which people with serious mental health conditions choose the services and supports that work best for them to support their recovery-is a tool that may directly and uniquely promote the social determinants of health by expanding the bounds of traditional service delivery to address the needs of the whole person.

A Case Study of a Peer Respite's Integration into a Public Mental Health System.

Peer respites are short-term residential mental health programs staffed by peers with lived experience of mental distress. This case study examines qualitative data of peer staff and non-peer program directors' experiences working at the first peer respite in California. Throughout a five-year study (2010-2015), researchers conducted 20 semi-structured interviews and three focus groups with 25 peer staff and three program directors. The study found that peer staff reported differences in recovery-oriented service delivery between the county health system and their training in Intentional Peer Support. Peer staff indicated that such differences contributed, in part, to the program's gradual acceptance of the service delivery model promoted by the county, and the program's integration enabled its continued support via public funds. This paper concludes with policy recommendations to transform public mental health systems in collaboration with peer staff.

Service Utilization Before and After Self-Direction: A Quasi-experimental Difference-in-Differences Analysis of Utah's Mental Health Access to Recovery Program.

Mental health self-direction involves participant control of an individualized budget to support recovery and wellness goals. This quasi-experimental study examined whether self-direction is associated with changes in service utilization. The study involved 2 years of administrative data for 94 self-directing participants and a matched comparison group of 529 non-participants with similar observed characteristics. Difference-in-differences were examined using four regression models predicting changes in four service utilization categories. Self-directing participants had greater increases in outpatient and rehabilitation services than the non-self-directing group, controlling for relevant covariates. There were no between-group differences in residential and emergency service utilization.

Service costs and mental health self-direction: Findings from consumer recovery investment fund self-directed care.

OBJECTIVE: Mental health self-direction, also known as self-directed care, involves an individual budget controlled by the participant with support from a specially trained recovery coach. The model under study here, implemented in a Medicaid behavioral health managed care context, allowed individuals to intentionally reduce mental health service use and apply cost savings as "Freedom Funds" to purchase a range of goods and services that are not typically considered mental health services to support recovery. This pre-post study examined mental health service utilization and cost before and after participating in self-direction. METHODS: The study involved Medicaid claims data for 45 self-directing participants over a 3-year period. Bivariate statistics were computed to identify meaningful pre-post differences in service utilization and standardized monthly costs. RESULTS: Median standardized monthly mental health clinical outpatient costs were significantly lower after self-direction participation compared to before. Participants spent a mean of $182 per month in Freedom Funds to purchase a range of nonclinical goods and services to work toward recovery goals. Total service costs-including Freedom Funds used during self-direction-did not differ significantly before and after program participation. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: Findings from this modest pre-post examination of self-direction suggest that mental health self-direction can result in more person-driven, individualized services without increasing costs. More research is needed to examine the cost-effectiveness of self-direction and to understand how program design and implementation factors influence the relationship between self-direction and service costs. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Housing and Employment Outcomes for Mental Health Self-Direction Participants.

OBJECTIVE: In self-direction, participants control individual budgets, allocating service dollars according to needs and preferences within program parameters to meet self-defined recovery goals. Mental health self-direction is associated with enhanced wellness and recovery outcomes at lower or similar cost than traditional service arrangements. This study compared outcomes of housing independence and employment between individuals who participated in self-direction and those who did not. METHODS: This quasi-experimental study involved administrative data from 271 self-directing participants. Using coarsened exact matching with observed demographic, diagnostic, and other characteristics, the authors constructed a comparison group of non-self-directing individuals (N=1,099). The likelihood of achieving positive outcomes between first and last assessments during the approximately four-year study period was compared for self-directing and non-self-directing individuals. RESULTS: Self-directing participants were more likely than nonparticipants to increase days worked for pay or maintain days worked at 20 or more days in the past 30 days (number needed to treat [NNT]=18; small effect size) and maintain or attain independent housing (NNT=16; small effect size), when analyses controlled, to the extent possible, for observed individual characteristics. CONCLUSIONS: Based on data from the nation's largest and longest-standing program of its kind, results suggest that mental health self-direction is associated with modest improvements or maintenance of positive outcomes in employment and housing independence. This research adds to the literature examining self-direction in the context of mental health and begins to fill the need for a greater understanding of self-direction's relationship to outcomes of interest to service users and families, providers, and system administrators.

The Emergence of Mental Health Self-Direction: An International Learning Exchange.

Self-direction has emerged worldwide as a promising practice for persons with serious mental health conditions and as a means toward creating more person-centered service systems. In self-direction, service users control an individualized budget, purchasing goods or services that can help them achieve personal recovery goals. This Open Forum describes an international learning exchange meeting, held in September 2015, in which experts in self-direction and mental health from seven nations convened for sharing best practices, discussing challenges, and laying the groundwork for a learning community to support the continued development of self-direction. Meeting participants identified three themes that represent next steps toward ensuring that the promise of self-direction is realized. First, self-direction involves creating a culture shift for value-based systems change. Second, people with lived experience must be involved and supported at every level, including direct support, leadership, and oversight. Third, stakeholder communication about self-direction's impact is critical.

Participants' Assessment of the Impact of Behavioral Health Self-Direction on Recovery.

Self-direction involves managing a flexible budget, selecting and purchasing services and supports to meet individual needs and preferences. An emerging practice in the behavioral health field, self-direction is part of a systemic shift toward person-centered approaches to service provision. To understand the relationship between recovery and self-direction, the authors conducted a content analysis of 30 in-depth interviews with individuals from two self-direction programs in one state. A positive relationship between self-direction and recovery was established. Meeting basic needs for food, clothing, and shelter are important first steps in the recovery process for self-directing participants. Recovery domains were dynamic and interrelated, with gains in independence, self-esteem, and self-confidence facilitating achievement of goals in other domains. To maximize the benefits of self-direction, program administrators may need to develop clearer program implementation standards and address poverty and limited access to appropriate behavioral health services and supports.

Impact of the 2nd story peer respite program on use of inpatient and emergency services.

OBJECTIVE: By providing a safe and supportive space for individuals experiencing or at risk of experiencing a mental health crisis, a peer respite may reduce the need for traditional crisis interventions. This study examined the relationship between peer respite and use of inpatient and emergency services among adults receiving publicly funded behavioral health services. METHODS: This analysis used propensity score matching to create matched pairs of 139 users of peer respite and 139 nonusers of respite with similar histories of behavioral health service use and clinical and demographic characteristics. A two-stage regression model first predicted the likelihood of inpatient or emergency service use after peer respite start date and then predicted hours of inpatient and emergency service use among 89 individuals who used any inpatient or emergency services. RESULTS: After the authors controlled for relevant covariates, the odds of using any inpatient or emergency services after the program start date were approximately 70% lower among respite users than nonrespite users, although the odds increased with each additional respite day. Among individuals who used any inpatient or emergency services, a longer stay in respite was associated with fewer hours of inpatient and emergency service use. However, the association was one of diminishing returns, with negligible decreases predicted beyond 14 respite days. CONCLUSIONS: By reducing the need for inpatient and emergency services for some individuals, peer respites may increase meaningful choices for recovery and decrease the behavioral health system's reliance on costly, coercive, and less person-centered modes of service delivery.

Peer respites: a research and practice agenda.

Peer respites are voluntary, short-term residential programs designed to support individuals experiencing or at risk of a psychiatric crisis. These programs posit that for many mental health services users, traditional psychiatric emergency department and inpatient hospital services are undesirable and avoidable when less coercive or intrusive community-based supports are available. Intended to provide a safe and homelike environment, peer respites are usually situated in residential neighborhoods. These programs are starting to spread across the United States, yet there is very little rigorous research on whether they are being implemented consistently across sites and which processes and outcomes may lead to benefits for persons experiencing psychiatric crises and for overburdened mental health systems. This Open Forum outlines implementation and research issues that peer respites face.

The impact of job accommodations on employment outcomes among individuals with psychiatric disabilities.

OBJECTIVE: This study aimed to fill a gap in the literature on effectiveness of employment accommodations by comparing employment outcomes for individuals with psychiatric disabilities who received or did not receive accommodations, with models informed by a conceptual approach blending static labor supply theory, Sen's capability approach, and the International Classification of Functioning. METHODS: Data for the study came from a longitudinal, four-year eight-state multisite demonstration project funded by the U.S. Department of Health and Human Services' Substance Abuse and Mental Health Services Administration. All participants had been recruited from clinical populations receiving outpatient psychiatric services. The effects of job accommodations on hours worked were assessed with generalized linear modeling (N=1,538). The effects of job accommodations on duration of employment were assessed with a parametric duration model analysis (N=1,040) that incorporated multiple spells of employment among individuals over the study period. RESULTS: Controlling for covariates suggested by the conceptual model, analyses showed that individuals who reported job accommodations on average worked 7.68 more hours per month and those who reported receiving accommodations worked 31% longer, with each job accommodation reported decreasing the risk of job termination by nearly 13%. CONCLUSIONS: Results demonstrate that job accommodations show potential to improve employment outcomes for individuals with psychiatric disabilities receiving supported employment services, indicating that job accommodations should be stressed in policy and continuing education efforts for program staff and clients.

Care integration in the Patient Protection and Affordable Care Act: implications for behavioral health.

Individuals with co-occurring serious mental illness and substance use disorders experience a highly fragmented system of care, contributing to poor health outcomes and elevated levels of unmet treatment needs. Several elements in the health care reform law may address these issues by enhancing the integration of physical and behavioral health care systems. The purpose of this paper is to analyze these elements, which fall into three domains: increasing access, restructuring financing and reimbursement mechanisms, and enhancing infrastructure. We conclude with a consideration of the implementation challenges that lie ahead.