System-level barriers to personal recovery in mental health: qualitative analysis of co-productive narrative dialogues between users and professionals.

BACKGROUND: No co-productive narrative synthesis of system-level facilitators and barriers to personal recovery in mental illness has been undertaken. AIMS: To clarify system-level facilitators and barriers to personal recovery of people with mental illness. METHOD: Qualitative study guided by thematic analysis. Data were collected through one focus group, which involved seven service users and three professionals. This group had 11 meetings, each lasting 2 h at a local research institute, between July 2016 to January 2018. RESULTS: The analysis yielded three themes: barriers inhibiting positive interaction within personal relationship networks, roots of barriers from mental health systems and the social cultural context, and possible solutions to address the roots. Barriers were acknowledged as those related to sense of safety, locus of control within oneself and reunion with self. The roots of barriers were recognised within mental health services, including system without trauma sensitivity, lack of advocacy support and limited access to psychosocial approaches. Roots from social cultural context were also found. There were no narratives relating to facilitators. A possible solution was to address the roots from systems. Social cultural change was called for that makes personalised goals most valued, with an inclusive design that overcomes stigma, to achieve an open and accepting community. CONCLUSIONS: The analysis yielded system-level barriers specific to each recovery process. Roots of barriers that need transformation to facilitate personal recovery were identified within mental health services. Social interventions should be further explored to translate the suggested social cultural changes into action.

Predictors of moving on from mental health supported accommodation in England: national cohort study.

BACKGROUND: Around 60 000 people in England live in mental health supported accommodation. There are three main types: residential care, supported housing and floating outreach. Supported housing and floating outreach aim to support service users in moving on to more independent accommodation within 2 years, but there has been little research investigating their effectiveness. AIMS: A 30-month prospective cohort study investigating outcomes for users of mental health supported accommodation. METHOD: We used random sampling, accounting for relevant geographical variation factors, to recruit 87 services (22 residential care, 35 supported housing and 30 floating outreach) and 619 service users (residential care 159, supported housing 251, floating outreach 209) across England. We contacted services every 3 months to investigate the proportion of service users who successfully moved on to more independent accommodation. Multilevel modelling was used to estimate how much of the outcome and cost variations were due to service type and quality, after accounting for service-user characteristics. RESULTS: Overall 243/586 participants successfully moved on (residential care 15/146, supported housing 96/244, floating outreach 132/196). This was most likely for floating outreach service users (versus residential care: odds ratio 7.96, 95% CI 2.92-21.69, P < 0.001; versus supported housing: odds ratio 2.74, 95% CI 1.01-7.41, P < 0.001) and was associated with reduced costs of care and two aspects of service quality: promotion of human rights and recovery-based practice. CONCLUSIONS: Most people do not move on from supported accommodation within the expected time frame. Greater focus on human rights and recovery-based practice may increase service effectiveness.

Intentions and experiences of effective practice in mental health specific supported accommodation services: a qualitative interview study.

BACKGROUND: Deinstitutionalisation in Europe has led to the development of community-based accommodation for people with mental health problems. The type, setting, and intensity of support provided vary and the costs are substantial. Yet, despite the large investment in these services, there is little clarity on their aims and outcomes or how they are regarded by staff and the clients. METHODS: We interviewed 30 staff and 30 clients from the three main types of supported accommodation in England (residential care, supported housing, floating outreach) to explore their perspectives on the purpose of these services, and the components of care considered most helpful. The interviews were coded and analysed using thematic analysis. RESULTS: There were generally consistent understandings amongst clients and staff across service types on the goals and purposes of supported accommodation services as: building independence and confidence; supporting people with their mental health; and providing safety and stability. We also noted a competing theme of anxiety about the continuity of support when clients move on from a service. Themes on the experience of what aided effective practice centred on: the supportive presence of others; incremental steps to progress; working together to avoid deskilling and dependency; feeling known and personally understood; tailoring support for social and community engagement; and building confidence through encouragement. CONCLUSIONS: The findings provide an understanding of the commonalities in service approach, and goals of clients in these services, as well as the facilitators of goal attainment. However, they also highlight a common tension between providing safe and supportive living environments, whilst also promoting independence and facilitating rehabilitative change.

Quality of life, autonomy, satisfaction, and costs associated with mental health supported accommodation services in England: a national survey.

BACKGROUND: Little research has been done into the effectiveness of mental health supported accommodation services. We did a national survey to investigate provision and costs of services and assess service user quality of life and outcomes across England. METHODS: We randomly sampled three types of services from 14 nationally representative regions-residential care, supported housing, and floating outreach-and recruited up to ten service users per service. Service quality and costs and service users' quality of life, autonomy, and satisfaction with care were assessed in a standardised manner with validated tools and compared by multilevel modelling. FINDINGS: 619 service users were recruited from 22 residential care, 35 supported housing, and 30 floating outreach services. Those in residential care and supported housing had more severe mental health problems than those in floating outreach. 348 (57%) were assessed as being at risk of severe self-neglect and 229 (37%) as being vulnerable to exploitation in the previous 2 years. Residential care was most expensive but provided for people with the greatest needs. The mean annual budget was £466 687 for residential care (range £276 000-777 920), compared with £365 452 for supported housing (£174 877-818 000), and £172 114 for floating outreach (£17 126-491 692). Quality of care was best in supported housing. People in supported housing and floating outreach were more socially included but experienced more crime than those in residential care. After adjustment for service quality and service user sociodemographic and clinical factors, quality of life was similar for service users in residential care and supported housing (mean difference -0·138, 95% CI -0·402 to 0·126, p=0·306) and lower for those in floating outreach than in residential care (-0·424, -0·734 to -0·114, p=0·007). However, autonomy was greater for those in supported housing than for those in residential care (0·145, 0·010 to 0·279, p=0.035). Satisfaction with care was similar across services. INTERPRETATION: Supported housing might be cost-effective, but the benefits need to be weighed against the risks associated with increased autonomy. FUNDING: National Institute for Health Research.

Adaptation of the Quality Indicator for Rehabilitative Care (QuIRC) for use in mental health supported accommodation services (QuIRC-SA).

BACKGROUND: No standardised tools for assessing the quality of specialist mental health supported accommodation services exist. To address this, we adapted the Quality Indicator for Rehabilitative care-QuIRC-that was originally developed to assess the quality of longer term inpatient and community based mental health facilities. The QuIRC, which is completed by the service manager and gives ratings of seven domains of care, has good psychometric properties. METHODS: Focus groups with staff of the three main types of supported accommodation in the UK (residential care, supported housing and floating outreach services) were carried out to identify potential amendments to the QuIRC. Additional advice was gained from consultation with three expert panels, two of which comprised service users with lived experience of mental health and supported accommodation services. The amended QuIRC (QuIRC-SA) was piloted with a manager of each of the three service types. Item response variance, inter-rater reliability and internal consistency were assessed in a random sample of 52 services. Factorial structure and discriminant validity were assessed in a larger random sample of 87 services. RESULTS: The QuIRC-SA comprised 143 items of which only 18 items showed a narrow range of response and five items had poor inter-rater reliability. The tool showed good discriminant validity, with supported housing services generally scoring higher than the other two types of supported accommodation on most domains. Exploratory factor analysis showed that the QuIRC-SA items loaded onto the domains to which they had been allocated. CONCLUSIONS: The QuIRC-SA is the first standardised tool for quality assessment of specialist mental health supported accommodation services. Its psychometric properties mean that it has potential for use in research as well as audit and quality improvement programmes. A web based application is being developed to make it more accessible which will produce a printable report for the service manager about the performance of their service, comparison data for similar services and suggestions on how to improve service quality.

Development and psychometric properties of the client's assessment of treatment scale for supported accommodation (CAT-SA).

BACKGROUND: Patient-Reported Outcome Measures (PROMs) are important for evaluating mental health services. Yet, no specific PROM exists for the large and diverse mental health supported accommodation sector. We aimed to produce and validate a PROM specifically for supported accommodation services, by adapting the Client's Assessment of Treatment Scale (CAT) and assessing its psychometric properties in a large sample. METHODS: Focus groups with service users in the three main types of mental health supported accommodation services in the United Kingdom (residential care, supported housing and floating outreach) were conducted to adapt the contents of the original CAT items and assess the acceptability of the modified scale (CAT-SA). The CAT-SA was then administered in a survey to service users across England. Internal consistency was assessed using Cronbach's alpha. Convergent validity was tested through correlations with subjective quality of life and satisfaction with accommodation, as measured by the Manchester Short Assessment of Quality of Life (MANSA). RESULTS: All seven original items of the CAT were regarded as relevant to appraisals of mental health supported accommodation services, with only slight modifications to the wording required. In the survey, data were obtained from 618 clients. The internal consistency of the CAT-SA items was 0.89. Mean CAT-SA scores were correlated with the specific accommodation item on the MANSA (r s = 0.37, p ˂ .001). CONCLUSIONS: The content of the CAT-SA has relevance to service users living in mental health supported accommodation. The findings from our large survey show that the CAT-SA is acceptable across different types of supported accommodation and suggest good psychometric properties. The CAT-SA appears a valid and easy to use PROM for service users in mental health supported accommodation services.

Uses of strength-based interventions for people with serious mental illness: A critical review.

BACKGROUND: For the past 3 decades, mental health practitioners have increasingly adopted aspects and tools of strength-based approaches. Providing strength-based intervention and amplifying strengths relies heavily on effective interpersonal processes. AIM: This article is a critical review of research regarding the use of strength-based approaches in mental health service settings. The aim is to discuss strength-based interventions within broader research on recovery, focussing on effectiveness and advances in practice where applicable. METHOD: A systematic search for peer-reviewed intervention studies published between 2001 and December 2014 yielded 55 articles of potential relevance to the review. RESULTS: Seven studies met the inclusion criteria and were included in the analysis. The Quality Assessment Tool for Quantitative Studies was used to appraise the quality of the studies. Our review found emerging evidence that the utilisation of a strength-based approach improves outcomes including hospitalisation rates, employment/educational attainment, and intrapersonal outcomes such as self-efficacy and sense of hope. CONCLUSION: Recent studies confirm the feasibility of implementing a high-fidelity strength-based approach in clinical settings and its relevance for practitioners in health care. More high-quality studies are needed to further examine the effectiveness of strength-based approaches.

Competing priorities: staff perspectives on supporting recovery.

Recovery has come to mean living a life beyond mental illness, and recovery orientation is policy in many countries. The aims of this study were to investigate what staff say they do to support recovery and to identify what they perceive as barriers and facilitators associated with providing recovery-oriented support. Data collection included ten focus groups with multidisciplinary clinicians (n = 34) and team leaders (n = 31), and individual interviews with clinicians (n = 18), team leaders (n = 6) and senior managers (n = 8). The identified core category was Competing Priorities, with staff identifying conflicting system priorities that influence how recovery-oriented practice is implemented. Three sub-categories were: Health Process Priorities, Business Priorities, and Staff Role Perception. Efforts to transform services towards a recovery orientation require a whole-systems approach.

Vocational rehabilitation in early psychosis: cluster randomised trial.

BACKGROUND: Individual placement and support (IPS) is effective in helping patients return to work but is poorly implemented because of clinical ambivalence and fears of relapse. AIMS: To assess whether a motivational intervention (motivational interviewing) directed at clinical staff to address ambivalence about employment improved patients' occupational outcomes. METHOD: Two of four early intervention teams that already provided IPS were randomised to receive motivational interviewing training for clinicians, focused on attitudinal barriers to employment. The trial was registered with the International Standard Randomised Controlled Trial Register (ISRCTN71943786). RESULTS: Of 300 eligible participants, 159 consented to the research. Occupational outcomes were obtained for 134 patients (85%) at 12-month follow-up. More patients in the intervention teams than in the IPS-only teams achieved employment by 12 months (29/68 v. 12/66). A random effects logistic regression accounting for clustering by care coordinator, and adjusted for participants' gender, ethnicity, educational and employment history and clinical status scores, confirmed superiority of the intervention (odds ratio = 4.3, 95% CI 1.5-16.6). CONCLUSIONS: Employment outcomes were enhanced by addressing clinicians' ambivalence about their patients returning to work.

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.

RECOVERY: Implementing recovery in mental health services.

The ideas of 'recovery' arise from the experiences of people with mental health problems. The recovery approach emerged in the North American civil rights and consumer and survivor movements from the 1970s onwards. It is concerned with social justice, individual rights, citizenship, equality, freedom from prejudice and discrimination. In this paper we discuss a project in England that has examined how mental health services may be transformed to be more supportive of recovery and the implications that this has for professional practice.

First episode psychosis and employment: a review.

Despite considerable growth in treatments, interventions, services and research of young people with a first episode of psychosis, little attention has been given to the priorities of these young people, in particular, gaining employment. A literature review was undertaken with the aim of investigating: 1) whether young people with a first episode of psychosis want to work, 2) what challenges they experience regarding work, 3) what is understood about employment outcomes, 4) what the most effective interventions to enable them to gain employment may be, and 5) what the associated costs may be. The review found that these young people appear to want to work yet face a range of psychological and social challenges to achieving this. Typically by the time they first come into contact with mental health services a proportion are already falling out of education and employment, and this decline continues with contact with services. However, there are specific interventions that can support them to gain employment. The Individual Placement and Support approach, adapted to include support to fulfil educational goals, has demonstrated that a mean of 69% of young people with a first episode of psychosis can gain education and employment compared to 35% of controls.

In-patient and residential alternatives to standard acute psychiatric wards in England.

BACKGROUND: Acute psychiatric wards have been the focus of widespread dissatisfaction. Residential alternatives have attracted much interest, but little research, over the past 50 years. AIMS: Our aims were to identify all in-patient and residential alternatives to standard acute psychiatric wards in England, to develop a typology of such services and to describe their distribution and clinical populations. METHOD: National cross-sectional survey of alternatives to standard acute in-patient care. RESULTS: We found 131 services intended as alternatives. Most were hospital-based and situated in deprived areas, and about half were established after 2000. Several clusters with distinctive characteristics were identified, ranging from general acute wards applying innovative therapeutic models, through clinical crisis houses that are highly integrated with local health systems, to more radical voluntary sector alternatives. Most people using the alternatives had a previous history of admission, but only a few community-based services accepted compulsory admissions. CONCLUSIONS: Alternatives to standard acute psychiatric wards represent an important, but previously undocumented and unevaluated, sector of the mental health economy. Further evidence is needed to assess whether they can improve the quality of acute in-patient care.

Research in supported housing.

BACKGROUND: De-institutionalization has led to the provision of various forms of housing with or without support for people with mental illness in the community. In this paper, we review the conceptual issues related to the provision of supported housing schemes, the characteristics of residents, research methods and outcomes, and the factors influencing the quality of care provided. METHODS: A Medline and hand search of published literature was complemented by information derived from contacting expert researchers in the field. FINDINGS: There is considerable diversity of models of supported housing and inconsistent use of terminology to describe them. This makes it difficult to compare schemes, processes, and outcomes. Patients in supported housing are characterized by deficits in self-care and general functioning, whilst behavioral problems such as violence, drug abuse and extreme antisocial habits predict exclusion from supported housing. Most evaluative studies are merely descriptive. In terms of outcomes, it seems that functioning can improve, social integration can be facilitated, and residents are generally more satisfied in supported housing compared with conventional hospital care. Further evidence suggests that most patients prefer regimes with low restrictiveness and more independent living arrangements, although loneliness and isolation have occasionally been reported to be a problem. Little information is available on the factors that mediate outcomes and on skills required by staff. CONCLUSION: Research in supported housing for psychiatric patients has so far been neglected. Large scale surveys on structure, process, and outcomes across a variety of housing schemes may be useful in the future to identify some of the key variables influencing outcomes. The use of direct observation methods in conjunction with other more conventional, standardized instruments may also highlight areas for improvement. In conducting research, structure and process, as well as outcomes, need to be considered. Thus, we need to know not just what to provide, but how to provide it in such a way that it will maximize beneficial outcomes. This represents a considerable research agenda.