The effects of a staff-training program in behavior management and social-learning principles on staff-patient interactions within a psychiatric rehabilitation inpatient unit.

Despite the existence of effective behavioral interventions for people diagnosed with serious mental illness (SMI), these continue to be underutilized. Barriers to implementation include a low frequency of staff-patient interactions, as well as a lack of knowledge about, and negative attitudes toward, behavioral interventions. Therefore, we examined the effects of a mandatory behavioral staff-training program on staff-patient interactions on a long-term psychiatric inpatient program for individuals with SMI. Staff-training consisted of two-phases: didactic training followed by a written exam, and in vivo training and assessment. From pre- to posttraining, all staff demonstrated increased positive and therapeutic behaviors and decreased negative behaviors when interacting with patients. Additionally, at baseline, nonmedical staff (psychologists, social workers) displayed significantly more therapeutic and fewer negative behaviors compared with medical staff (psychiatrists, nurses, mental health workers), and this pattern persisted at posttraining despite improvements in both groups. Importantly, completion of the staff-training program was associated with improvements in patient behavior. Although both written and in vivo test scores significantly predicted change in negative staff behaviors toward patients, the in vivo test performance increased predictive ability over and above that of written test performance. Staff who disagreed with behavioral management principles displayed less improvement in negative behaviors from pre- to postassessment. These data have implications for clarifying staff training needs in programs for chronically ill people with SMI. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Enhancing and Promoting Recovery In Attentionally Impaired People Diagnosed With Schizophrenia: Results From A Randomized Controlled Trial Of Attention Shaping In A Partial Hospital Program.

The attentional impairments associated with schizophrenia are well-documented and profound. Psychopharmacological and most psychosocial interventions have been shown to have limited effect in improving attentional capacity. That said, one form of psychosocial treatment, attention shaping procedures (ASP), has been repeatedly demonstrated to produce significant and meaningful change in various aspects of participant attentiveness behaviors. To date, studies of ASP have been limited in that they have been conducted primarily with inpatients, have not assessed the generalizability of ASP's effects, and have not explored whether reinforcement is required to be contingent on performance of attentive behaviors. To address these limitations we conducted the first randomized clinical trial of ASP with people diagnosed with schizophrenia who are being treated in a partial hospital program. Our results indicate that ASP is effective in improving attention in people with schizophrenia in these types of programs, the effects of ASP generalize outside of the immediate treatment context to both other treatment groups and real world functioning, and contingent reinforcement is a critical ingredient of ASP. This project provides further evidence for the benefits of use of ASP in the recovery-oriented treatment of people diagnosed with schizophrenia who have significant attentional impairments.

Enrollment in supported employment services for clients with a co-occurring disorder.

OBJECTIVE: People with serious mental illnesses and co-occurring substance use disorders are often excluded from vocational services, despite the lack of evidence that having a substance use disorder prevents them from being able to work. This study explored enrollment in supported employment services among clients with and without co-occurring substance use disorders. METHODS: With data from electronic medical records from a psychiatric rehabilitation agency, relationships between co-occurring substance use disorders and supported employment were examined among 1,748 clients with serious mental illnesses who were consecutively admitted to the agency over a two-year period. RESULTS: Despite a similar interest in employment, clients with a co-occurring substance use disorder were 52% less likely than those without to enroll in a supported employment program. Those who were enrolled had similar competitive employment rates (25% for those with co-occurring disorders and 28% for those without). CONCLUSIONS: People with co-occurring substance disorders have reduced rates of enrollment in supported employment services.

Integrated primary and mental health care services: an evolving partnership model.

TOPIC: Persons with serious psychiatric disabilities experience high rates of medical co-morbidities that, if properly treated, could improve overall well-being and the course of recovery. PURPOSE: This brief reports describes how two organizations-Thresholds Psychiatric Rehabilitation Centers and University of Illinois College of Nursing-partnered to offer integrated behavioral and physical health care responsive to the needs of the population and committed to consumer-centered, holistic and preventative care. Most recently, the partnership offers primary care in different community settings through different service models-tele-monitoring, home visits, group visits. SOURCES USED: A combination of published literature, staff report, and quality assurance data informs this report. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: The authors conclude that primary care outreach is a promising strategy in mental health settings and that the Chronic Care Model (CCM) provides a set of guidelines for designing and monitoring quality integrated care for a partnership model of integrated care.

Paxton house: integrating mental health and diabetes care for people with serious mental illnesses in a residential setting.

OBJECTIVE: This report provides a program description of a supported housing residence for individuals with co-occurring diabetes and serious mental illnesses and preliminary health outcome data. METHODS: Weight, blood glucose levels and satisfaction survey data were collected retrospectively on 13 individuals referred to the program. RESULTS: Results indicate that individuals lost weight and fasting glucose readings fell into the ADA recommended range in the first six months of participation. Overall, consumers participating in the program were satisfied with the diabetes education and monitoring services provided. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: While preliminary results suggest that consumers benefit, this study only begins to address how integrated behavioral health and diabetes-specific programming in residential settings meets the needs of persons with severe mental illnesses and diabetes. A more thorough understanding of the impact of these programs on consumers' health outcomes is needed to inform how to deliver diabetes management curricula and support consumers to improve their overall health.

Trial of an electronic decision support system to facilitate shared decision making in community mental health.

OBJECTIVES: Involvement of community mental health consumers in mental health decision making has been consistently associated with improvements in health outcomes. Electronic decision support systems (EDSSs) that support both consumer and provider decision making may be a sustainable way to improve dyadic communication in a field with approximately 50% workforce turnover per year. This study examined the feasibility of such a system and investigated proximal outcomes of the system's performance. METHODS: A cluster randomized design was used to evaluate an EDSS at three urban community mental health sites. Case managers (N=20) were randomly assigned to the EDSS-supported planning group or to the usual care planning group. Consumers (N=80) were assigned to the same group as their case managers. User satisfaction with the care planning process was assessed for consumers and case managers (possible scores range from 1 to 5, with higher summary scores indicating more satisfaction). Recall of the care plan was assessed for consumers. Linear regression with adjustment for grouping by worker was used to assess satisfaction scores. A Wilcoxon rank-sum test was used to examine knowledge of the care plan. RESULTS: Compared with case managers in the control group, those in the intervention group were significantly more satisfied with the care planning process (mean ± SD score=4.0 ± .5 versus 3.3 ± .5; adjusted p=.01). Compared with consumers in the control group, those in the intervention group had significantly greater recall of their care plans three days after the planning session (mean proportion of plan goals recalled=75% ± 28% versus 57% ± 32%; p=.02). There were no differences between the clients in the intervention and control groups regarding satisfaction. CONCLUSIONS: This study demonstrated that clients can build their own care plans and negotiate and revise them with their case managers using an EDSS.

Access to supported employment for consumers with criminal justice involvement.

OBJECTIVE: This paper aims to provide further understanding of the influence of severe mental illness (SMI) and criminal justice involvement (CJI) on access to Supported Employment (SE) services. The authors investigate differences between consumers with and without CJI regarding access to SE and explore reasons for group differences. METHOD: This study employs a mixed-methods design. The quantitative portion compares employment service utilization of consumers with CJI to consumers without CJI to examine hypothesized differences in frequency of access and time to receipt of SE services. The qualitative portion includes in-depth, individual interviews with consumers with CJI and service providers to gain various perspectives on consumers' with CJI entry to SE. RESULTS: Consumers with CJI take longer to access SE services. Consumers with CJI and service providers identify the following as barriers or facilitators to access to SE: competing challenges for consumers with CJI such as mental health probation, the adverse impact of CJI on consumers' psychosocial functioning, social networks, consumers' relationships with practitioners, and practitioners' relationship with SE. CONCLUSIONS: Consumers with CJI do receive SE services at the same rate as those without CJI, but it takes them substantially longer to engage in SE services. Both programmatic and policy level interventions and modifications may ameliorate this problem.

Psychotherapy and recovery from schizophrenia: A review of potential applications and need for future study.

Recovery from schizophrenia has been conceptualized to involve not only symptom remission of symptoms and achievement of psychosocial milestones but also subjective changes in how persons appraise their lives and the extent to which they experience themselves as meaningful agents in the world. In this paper we review the potential of individual psychotherapy to address these more subjective aspects of recovery. Literature on the effectiveness of psychotherapy for persons with schizophrenia is discussed and two different paths by which psychotherapy might modify self-experience are described. First we detail how psychotherapy could be conceptualized and tailored to help persons with schizophrenia to construct richer and fuller narrative accounts of their lives including their strengths, challenges, losses and hopes. Second we explore how psychotherapy could target the capacity for metacognition or thinking about thinking, assisting persons with psychosis to become able to think about themselves and others in a generally more complex and flexible manner. The needs for future research are discussed along with a commentary on how current evidence- and skill-based treatments may contain key elements which could be considered psychotherapeutic.

A comparative study of the MATRICS and IntegNeuro cognitive assessment batteries.

Cognitive impairment is prevalent in schizophrenia and is related to poorer functional and treatment outcomes. Cognitive assessment is therefore now a routine component of clinical trials of new treatments for schizophrenia. The current gold-standard for cognitive assessment in clinical trials for schizophrenia is the MATRICS (Measurement and Treatment Research to Improve Cognition in Schizophrenia) Consensus Cognitive Battery (MCCB), which was developed based on expert consensus and incorporates paper-and-pencil tests (and one computerized measure) with an established history in the field of neuropsychology. Recently, however, interest has increased in using computerized batteries for clinical trials. In this study, we tested 155 people with schizophrenia and 75 healthy control participants on both the MCCB and IntegNeuro, a touch-screen-based computerized battery with previously demonstrated high levels of reliability and validity, to determine comparability between test scores. In addition, we assessed test-retest reliability and practice effects over a one-month interval for both batteries and determined correlations between cognitive test scores and scores on functional outcome measures. High levels of agreement were observed between total battery composite scores (r > .80) and, in a canonical correlation analysis, between all critical single test scores from each battery (r(c) > .90). The batteries demonstrated essentially equivalent sensitivity in discriminating between patients and controls and equivalent levels of test-retest reliability and practice effects. Correlations between cognitive test scores and functional outcome measures were equivalent between the two batteries and low in nearly all cases. The number of missing data points was greater with IntegNeuro, highlighting the requirements for test administrator involvement even with computerized batteries.

SELF-STIGMA AND COMING OUT ABOUT ONE'S MENTAL ILLNESS.

Self-stigma can undermine self-esteem and self-efficacy of people with serious mental illness. Coming out may be one way of handling self-stigma and it was expected that coming out would mediate the effects of self-stigma on quality of life. This study compares coming out to other approaches of controlling self-stigma. Eighty-five people with serious mental illness completed measures of coming out (called the Coming Out with Mental Illness Scale, COMIS), self-stigma, quality of life, and strategies for managing self-stigma. An exploratory factor analysis of the COMIS uncovered two constructs: benefits of being out (BBO) and reasons for staying in. A mediational analysis showed BBO diminished self-stigma effects on quality of life. A factor analysis of measures of managing self-stigma yielded three factors. Benefits of being out was associated with two of these: affirming strategies and becoming aloof, not with strategies of shame. Implications for how coming out enhances the person's quality of life are discussed.

Self-stigma, group identification, perceived legitimacy of discrimination and mental health service use.

Stigma may interfere with mental health service use. We measured self-stigma and stigma-related cognitions (group identification and perceived legitimacy of discrimination) at baseline in 85 people with schizophrenia, schizoaffective or affective disorders. After 6 months, 75 (88%) had reported use of mental health services. Controlling for baseline psychopathology, perceived stigma and diagnosis, low perceived legitimacy of discrimination predicted use of counselling/psychotherapy. Strong group identification was associated with participation in mutual-help groups. More self-stigma predicted psychiatric hospitalisation. Cognitive indicators of stigma resilience may predict out-patient service use, whereas self-stigma may increase the risk of psychiatric hospitalisation.

Improving outcomes for pregnant and parenting foster care youth with severe mental illness: an evaluation of a transitional living program.

OBJECTIVE: This study provides preliminary evidence for the effectiveness of a residential program with comprehensive wrap-around services for pregnant and parenting foster care youth with severe mental illness or severe emotional disturbance who are preparing to transition to independent living. METHODS: Twenty-five females ages 18 to 21 participated. Program effectiveness was determined by tracking monthly status changes, such as education, employment, and hospitalizations, as well as by comparing scores on four bi-annually administered standardized assessments of parenting competency and stress, child maltreatment risk, and mental health symptoms. RESULTS: Assessment findings indicate that program participation is associated with positive changes in participants' familial relationships, family responsibility and care, proper parenting behavior and feelings, and parental distress and competency, but no change in mental health symptoms. Positive behavior changes associated with program participation were observed in education, employment, and low numbers of suspected and substantiated child maltreatment reports. Negative behavior changes associated with the program were frequency of AWOL incidents and subsequent pregnancies. CONCLUSIONS: This is the first study to evaluate a program designed for this very unique population and has implications for program design and policy. Future research with more rigorous experimental design is necessary in order to understand the critical ingredients of programs serving this vulnerable population.

A stress-coping model of mental illness stigma: I. Predictors of cognitive stress appraisal.

Stigma can be a major stressor for individuals with schizophrenia and other mental illnesses. It is unclear, however, why some stigmatized individuals appraise stigma as more stressful, while others feel they can cope with the potential harm posed by public prejudice. We tested the hypothesis that the level of perceived public stigma and personal factors such as rejection sensitivity, perceived legitimacy of discrimination and ingroup perceptions (group value; group identification; entitativity, or the perception of the ingroup of people with mental illness as a coherent unit) predict the cognitive appraisal of stigma as a stressor. Stigma stress appraisal refers to perceived stigma-related harm exceeding perceived coping resources. Stress appraisal, stress predictors and social cue recognition were assessed in 85 people with schizophrenia, schizoaffective or affective disorders. Stress appraisal did not differ between diagnostic subgroups, but was positively correlated with rejection sensitivity. Higher levels of perceived societal stigma and holding the group of people with mental illness in low regard (low group value) independently predicted high stigma stress appraisal. These predictors remained significant after controlling for social cognitive deficits, depressive symptoms and diagnosis. Our findings support the model that public and personal factors predict stigma stress appraisal among people with mental illness, independent of diagnosis and clinical symptoms. Interventions that aim to reduce the impact of stigma on people with mental illness could focus on variables such as rejection sensitivity, a personal vulnerability factor, low group value and the cognitive appraisal of stigma as a stressor.

A stress-coping model of mental illness stigma: II. Emotional stress responses, coping behavior and outcome.

Stigma can be a major stressor for people with schizophrenia and other mental illnesses, leading to emotional stress reactions and cognitive coping responses. Stigma is appraised as a stressor if perceived stigma-related harm exceeds an individual's perceived coping resources. It is unclear, however, how people with mental illness react to stigma stress and how that affects outcomes such as self-esteem, hopelessness and social performance. The cognitive appraisal of stigma stress as well as emotional stress reactions (social anxiety, shame) and cognitive coping responses were assessed by self-report among 85 people with schizophrenia, schizoaffective or affective disorders. In addition to self-directed outcomes (self-esteem, hopelessness), social interaction with majority outgroup members was assessed by a standardized role-play test and a seating distance measure. High stigma stress was associated with increased social anxiety and shame, but not with cognitive coping responses. Social anxiety and shame predicted lower self-esteem and more hopelessness, but not social performance or seating distance. Hopelessness was associated with the coping mechanisms of devaluing work/education and of blaming discrimination for failures. The coping mechanism of ingroup comparisons predicted poorer social performance and increased seating distance. The cognitive appraisal of stigma-related stress, emotional stress reactions and coping responses may add to our understanding of how stigma affects people with mental illness. Trade-offs between different stress reactions can explain why stress reactions predicted largely negative outcomes. Emotional stress reactions and dysfunctional coping could be useful targets for interventions aiming to reduce the negative impact of stigma on people with mental illness.

The Thresholds-Dartmouth partnership and research on shared decision making.

Thresholds Rehabilitation Centers is one of the largest providers of psychiatric rehabilitation services in the United States, and the Dartmouth Psychiatric Research Center is a highly regarded team of rehabilitation researchers. This column describes efforts to build upon the long-standing collaborative relationship between Thresholds (community partner) and Dartmouth (academic partner) to implement and study shared decision making in a community mental health care setting that serves an ethnoracially diverse population. Shared decision making encompasses a client-centered approach in which client and practitioner are equal partners. This joint project incorporates modern information technology, decision science, cultural competence, stakeholder collaboration, outcomes research, and training. The partnership itself provides an exemplar of shared decision making.

Reduced top-down influences in contour detection in schizophrenia.

INTRODUCTION: Chronic schizophrenia patients have previously demonstrated performance deficits in contour integration tasks. The purpose of this study was to investigate whether schizophrenia patients, spanning a range of illness severity, would demonstrate responsiveness to manipulations that recruit top-down processing strategies involving learning and sequencing effects in a contour integration task. METHODS: We administered a contour integration test over four consecutive days and in two different presentation conditions each day. In one condition, the stimuli were administered in order of increasing difficulty, and in the other they were presented in random order. The order in which these two conditions were presented was counterbalanced across days and participants. In addition, a nonschizophrenia psychotic disorders control group was included to determine if past findings of a contour integration deficit in schizophrenia could be replicated in the presence of a symptomatically similar control group. RESULTS: All groups demonstrated similar learning curves across the four days and generally similar overall levels of performance, with the exception of the group of the most chronic schizophrenia patients. In addition, the order in which the stimuli were presented to subjects affected their performance, with higher scores achieved for all groups in the condition where the stimuli were presented in increasing order of difficulty. Interaction effects revealed that the effects of order presentation were greater for nonpatient than for psychotic patients. CONCLUSIONS: These data are further evidence that perceptual organization impairments in schizophrenia are illness severity-related, and that schizophrenia patients as a whole are less sensitive to top-down manipulations in this type of task.

Effectiveness of a two-phase cognitive rehabilitation intervention for severely impaired schizophrenia patients.

BACKGROUND: Several small-N, uncontrolled reports have demonstrated that the behavioral technique of attention shaping has significantly increased attention span among severely ill schizophrenia patients. METHOD: In this study, we evaluated the effectiveness of using an individually administered intervention for improving sustained attention, Attention Process Training (APT), followed by an attention-shaping procedure within the context of an ongoing skills training group. Patients were randomly assigned to receive either the APT and attention-shaping sequence (n = 18) or equivalent hours of treatment in the same intensive behavioral rehabilitation program (n = 13). RESULTS: Results indicated dramatic improvements in attentiveness in the cognitive rehabilitation condition compared with the control condition, which demonstrated essentially no change in attentiveness over the 12 weeks of treatment. The attention-shaping intervention appeared to account for the majority of the effect. In contrast to the observational data, performance on neuropsychological tests was unaffected by the cognitive interventions. CONCLUSIONS: This two-phase intervention demonstrated effectiveness in promoting attentive behavior among chronic schizophrenia patients with severe attentional impairment.