A cluster-randomised controlled trial of values-based training to promote autonomously held recovery values in mental health workers.

BACKGROUND: The implementation and use of evidence-based practices is a key priority for recovery-oriented mental health service provision. Training and development programmes for employees continue to be a key method of knowledge and skill development, despite acknowledged difficulties with uptake and maintenance of behaviour change. Self-determination theory suggests that autonomy, or a sense that behaviour is self-generated, is a key motivator to sustained behaviour change, in this case practices in mental health services. This study examined the utility of values-focused staff intervention as a specific, reproducible method of autonomy support. METHODS: Mental health workers (n = 146) were assigned via cluster randomisation to either a values clarification condition or an active problem-solving control condition. RESULTS: Results demonstrated that a structured values clarification exercise was useful in promoting integrated motivation for the changed practice and resulted in increased implementation planning. CONCLUSIONS: Structured values clarification intervention demonstrates utility as a reproducible means of autonomy support within the workplace. We discuss future directions for the study of autonomous motivation in the field of implementation science. TRIAL REGISTRATION: ACTRN12613000353796.

Measuring stages of recovery from psychosis.

BACKGROUND: Mental health consumers invite us to abandon the pathology model, which is tied to pessimism, and instead to embrace a model of personal recovery that goes beyond being free from symptoms, and involves self-management of the illness. The Stages of Recovery Instrument (STORI) is a measure developed from the perspective of consumers according to a conceptual five-stage model of recovery. AIMS: The main aim of this work was to study the psychometric properties of the STORI, but we also set out to compare the stages of recovery in our sample with the five-stage model in the sample with which the scale was developed. METHODS: Our sample consisted of 95 people diagnosed with schizophrenia-spectrum psychoses, with a mean age of 34.74 (SD=9.25). RESULTS: The STORI scores showed adequate psychometric properties in this sample. Cluster analysis indicated that the three-cluster model fitted the data better than the five-cluster model. Internal consistency of the STORI scores ranged between .83 and .87. STORI stages were associated with Recovery Styles Questionnaire scores. DISCUSSION: The results provide empirical validation of the STORI in other countries. Empirical evidence revealed that the stages of recovery found in our own and other clinical samples differ from those found in the samples with which the scale was developed.

A comparison of two coaching approaches to enhance implementation of a recovery-oriented service model.

Moving to recovery-oriented service provision in mental health may entail retraining existing staff, as well as training new staff. This represents a substantial burden on organisations, particularly since transfer of training into practice is often poor. Follow-up supervision and/or coaching have been found to improve the implementation and sustainment of new approaches. We compared the effect of two coaching conditions, skills-based and transformational coaching, on the implementation of a recovery-oriented model following training. Training followed by coaching led to significant sustained improvements in the quality of care planning in accordance with the new model over the 12-month study period. No interaction effect was observed between the two conditions. However, post hoc analyses suggest that transformational coaching warrants further exploration. The results support the provision of supervision in the form of coaching in the implementation of a recovery-oriented service model, and suggest the need to better elucidate the mechanisms within different coaching approaches that might contribute to improved care.

Improving implementation of evidence-based practice in mental health service delivery: protocol for a cluster randomised quasi-experimental investigation of staff-focused values interventions.

BACKGROUND: There is growing acceptance that optimal service provision for individuals with severe and recurrent mental illness requires a complementary focus on medical recovery (i.e., symptom management and general functioning) and personal recovery (i.e., having a 'life worth living'). Despite significant research attention and policy-level support, the translation of this vision of healthcare into changed workplace practice continues to elude. Over the past decade, evidence-based training interventions that seek to enhance the knowledge, attitudes, and skills of staff working in the mental health field have been implemented as a primary redress strategy. However, a large body of multi-disciplinary research indicates disappointing rates of training transfer. There is an absence of empirical research that investigates the importance of worker-motivation in the uptake of desired workplace change initiatives. 'Autonomy' is acknowledged as important to human effectiveness and as a correlate of workplace variables like productivity, and wellbeing. To our knowledge, there have been no studies that investigate purposeful and structured use of values-based interventions to facilitate increased autonomy as a means of promoting enhanced implementation of workplace change. METHODS: This study involves 200 mental health workers across 22 worksites within five community-managed organisations in three Australian states. It involves cluster-randomisation of participants within organisation, by work site, to the experimental (values) condition, or the control (implementation). Both conditions receive two days of training focusing on an evidence-based framework of mental health service delivery. The experimental group receives a third day of values-focused intervention and 12 months of values-focused coaching. Well-validated self-report measures are used to explore variables related to values concordance, autonomy, and self-reported implementation success. Audits of work files and staff work samples are reviewed for each condition to determine the impact of implementation. Self-determination theory and theories of organisational change are used to interpret the data. DISCUSSION: The research adds to the current knowledge base related to worker motivation and uptake of workplace practice. It describes a structured protocol that aims to enhance worker autonomy for imposed workplace practices. The research will inform how best to measure and conceptualise transfer. These findings will apply particularly to contexts where individuals are not 'volunteers' in requisite change processes. TRIAL REGISTRATION ACTRN: ACTRN12613000353796.

Development of a short measure of psychological recovery in serious mental illness: the STORI-30.

OBJECTIVE: To develop a brief measure of stage of psychological recovery from mental illness by identifying the best-performing items of the 50-item Stages of Recovery Instrument (STORI). METHOD: Item response modelling was used to identify a short form of the full-length STORI. The resulting items were subjected to factor analysis to further refine the subscales. A second data set was used to confirm the construct validity of the new measure. A correlational analysis was conducted to examine relationships among the five subscale scores. RESULTS: Analyses identified 30 items that represented the five stages of the full STORI. The five stage subscale scores of the shorter measure, the STORI-30, showed a pattern of correlations that demonstrated an ordinal relationship between the stages. CONCLUSIONS: There is a need for recovery-oriented measures to augment established clinical assessment tools. The shorter version of the STORI, the STORI-30, shows promise as a brief measure of stage of recovery, more feasible for routine clinical use. Further psychometric and longitudinal testing is recommended. Qualitative research would be valuable in establishing acceptability to consumers and the clinical usefulness of the STORI-30.

Reliability and validity of the Japanese version of the Self-Identified Stage of Recovery for people with long term mental illness.

The Self-Identified Stage of Recovery (SISR) is a two-part scale assessing both the stage of recovery (SISR-A) and the component processes of recovery (SISR-B) for people with mental illness. This study aimed to develop a Japanese version of the SISR and to examine its reliability and validity. The Japanese versions of the SISR-A and SISR-B were developed through focus group cognitive interviews and the translation-back translation procedure. A cross-sectional questionnaire survey was conducted of 223 participants who had long term mental illness, were aged 20 years or older, and currently living in communities and inpatient ward settings; 59.2% were males and the average age was 47.6 years. The questionnaire also included the 24-item Recovery Assessment Scale, Herth Hope Index, Empowerment Scale, and Resilience Scale. Cronbach's alpha coefficient, intraclass correlation coefficient, and weighted kappas were generally fair to high, and the SISR-A and SISR-B scores were positively correlated with other relevant scales. This study supported the reliability and validity of the Japanese versions of the SISR-A and SISR-B among people with long term mental illness in Japan.

Do clinical outcome measures assess consumer-defined recovery?

There is an international call for mental health services to become recovery-oriented, and also to use evidence-based practices. Addressing this call requires recovery-oriented measurement of outcomes and service evaluation. Mental health consumers view recovery as leading as meaningful life, and have criticised traditional clinical measures for being too disability-oriented. This study compares three measures of consumer-defined recovery from enduring mental illness: the Recovery Assessment Scale, the Mental Health Recovery Measure and the Self-Identified Stage of Recovery, with four conventional clinical measures. Correlational analyses supported the convergent validity of the recovery measures, although certain subscales were unrelated to each other. More importantly, little relationship was found between consumer-defined recovery and the clinical measures. Analyses of variance revealed that scores on the recovery measures increased across self-identified stage of recovery, but scores on most clinical measures did not improve consistently across stage of recovery. The findings demonstrate the qualitative difference between the two types of measures, supporting the claim by consumers that clinical measures do not assess important aspects of recovery. There is a need for further research and refinement of recovery measurement, including assessment of stages of recovery, with the aim of including such measures as an adjunct in routine clinical assessment, service evaluation and research.

Development of a structured interview schedule to assess stage of psychological recovery from enduring mental illness.

Abstract Objective. To develop a brief interview-based assessment tool, feasible for routine use in mental health service settings to measure an individual's stage of psychological recovery from an enduring mental illness. Method. Key indicators for each stage of psychological recovery were formulated according to the stages of psychological conceptual framework and an analysis of transcribed data wherein 17 consumer participants described their illness and recovery experiences. Upon development of the measure, Short Interview to assess Stages of Recovery (SIST-R), the instrument was evaluated by practitioners and consumers to examine its feasibility for use in mental health service settings. A pilot test with 18 mental health consumer participants compared results obtained by the SIST-R with those from an existing self-report stages of psychological recovery measure (STORI), a measure of psychological distress (K-10), and a measure of recovery (RAS). Results. Concordance between the SIST-R and the STORI was substantial (Somers' D = 0.61, P = 0.004). The mean scores from other recovery measures correspond with what could be theoretically expected across individual stages of recovery. Conclusion. This study contributes towards the strengthening of a recovery-oriented approach within clinical/mental health service settings with the development of an assessment tool that demonstrates potential clinical utility. There is a need to validate further the preliminary findings of this study.

Stages of recovery instrument: development of a measure of recovery from serious mental illness.

OBJECTIVE: In order to realize the vision of recovery-orientated mental health services, there is a need for a model and a method of measuring recovery as the concept is described by mental health consumers. A preliminary five-stage model based on consumer accounts was developed in an earlier study by the authors. This next stage of the research program describes the development and initial testing of a stage measure which, when validated, can be used in testing that model. METHOD: Existing measures of recovery were reviewed to assess their concordance with the model, and a new measure, the Stages of Recovery Instrument (STORI) was subsequently developed. A postal survey was conducted of 94 volunteers from the NISAD Schizophrenia Research Register. Participants completed the STORI and measures of mental health, psychological wellbeing, hope, resilience and recovery. RESULTS: The STORI correlated with all of the psychological health variables, and the five stage subscales were found to be internally consistent. An ordinal relationship between the stage subscales was demonstrated by the intercorrelations of the subscale scores and the pattern of correlations between the subscales and the other measures. However, a cluster analysis of items revealed an overlap in measurement of adjacent stages, with only three clear clusters emerging. CONCLUSIONS: The results provide preliminary empirical validation of the STORI as a measure of the consumer definition of recovery. However, refinement of the measure is needed to improve its capacity to discriminate between the stages of the model. The model could then be comprehensively tested using longitudinal methods and the inclusion of objective measures.

The experience of recovery from schizophrenia: towards an empirically validated stage model.

OBJECTIVE: The consumer movement is advocating that rehabilitation services become recovery-orientated. The objectives of this study are to gain a better understanding of the concept of recovery by: (i) identifying a definition of recovery that reflects consumer accounts; and (ii) developing a conceptual model of recovery to guide research, training and inform clinical practice. METHOD: A review was conducted of published experiential accounts of recovery by people with schizophrenia or other serious mental illness, consumer articles on the concept of recovery, and qualitative research and theoretical literature on recovery. Meanings of recovery used by consumers were sought to identify a definition of recovery. Common themes identified in this literature were used to construct a conceptual model reflecting the personal experiences of consumers. RESULTS: The definition of recovery used by consumers was identified as psychological recovery from the consequences of the illness. Four key processes of recovery were identified: (i) finding hope; (ii) re-establishment of identity; (iii) finding meaning in life; and (iv) taking responsibility for recovery. Five stages were identified: (i) moratorium; (ii) awareness; (iii) preparation; (iv) rebuilding; and (v) growth. CONCLUSION: A five-stage model compatible with psychological recovery is proposed, which offers a way forward for attaining recovery-orientated outcomes. After further empirical investigation, a version of this model could be utilized in quantitative research, clinical training and consumer education.