Annotated Bibliography for PSR Areas
of Employment, Education, Wellness,
Life & Leisure Skills, Family
Involvement and Peer Support
January, 2015
Introduction:
Annotated Bibliography Methodology and Qualifying Statement
This Annotated Bibliography is based on a comprehensive review, analysis and discussion of
the evidence based best and promising practices in the five life domains of focus: employment,
education, leisure, wellness and basic living skills.
The process for developing the Annotated Bibliography has included:
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
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A literature review which has focused on literature since 2000 until 2014. A search of
Psych Info, Psychlit, CINAHL, ERIC, and MEDLINE databases from 2000 to the
present was conducted using appropriate generic Key Words including psychosocial
rehabilitation, psychiatric rehabilitation, PSR as well as Key Words specific to each
section, e.g. supported employment, supported education, peer support, wellness,
illness management and recovery, life style, health education, psycho education for
families, self-management, nutrition, exercise and weight management
Consulting with an expert panel of key informants to advise on the latest references
Wherever possible, level 1 and 2 evidence has been used. Level 1 evidence includes
Cochrane and other rigorous reviews, Meta analyses and randomized controlled trials.
Level 2 evidence includes quasi experiments and correlational studies.
Grey literature has been included where it is considered to make a significant addition
to the body of knowledge
There are some limitations to the literature review on which this Annotated Bibliography is
based. PSR is a relatively new field and there is a shortage of substantial literature in several of
the topics, particularly supported education and leisure. Similarly, there is little literature on
PSR approaches for persons with substance use problems.
Supported Education
Background Articles
1.
Mueser, K. T., & Cook, J. A. (2012). Supported employment, supported education, and
career development. Psychiatric Rehabilitation Journal, 35(6), 417-420. doi:
10.1037/h0094573
Questions have been raised as to whether a narrow focus on job attainment may have be
at the cost of less career development and ultimately less meaningful work for the
consumers. At the same time, recent research shows that IPS may be effectively
delivered within an early psychosis intervention service delivery context.
Implications: Those with little previous job experience, including young adults, may
benefit from an approach that offers flexibility to pursue supported education as well as
supported employment. More research needs to be done on the effectiveness of
supported education, and its potential to further the career aspirations of people with
mental illness.
2.
Storrie, K., Ahern, K., & Tuckett, A. (2010). A systematic review: Students with mental
health problems—A growing problem. International Journal of Nursing Practice,16(1),
1-6. doi:10.1111/j.1440-172X.2009.01813.x.
A systematic review of the literature on the mental health needs of the post-secondary
student population. The article notes that the number of students worldwide with
mental health problems is growing. The majority of people with serious mental illness
want to attend college, but most who attend drop out without completing a degree.
Implications: Universities and other post-secondary institutions must take steps to
provide a supportive environment on campus. Specific actions include developing oncampus mental health expertise (for providing support and for helping students with
psychiatric disabilities develop accommodations to support their educational
endeavours), developing clear links with off-campus mental health providers, and
making students aware of these resources.
3.
Mansbach-Kleinfeld, I., Sasson, R., Shvarts, S., & Grinshpoon, A. (2007). What
education means to People with psychiatric disabilities: A content analysis. American
Journal of Psychiatric Rehabilitation, 10(4), 301-316. doi:10.1080/15487760701680554.
This qualitative paper examines the meaning of Supported Education (SEd) for
participants who had completed high school courses. The experience allowed people
with mental illness to recover lost roles and capabilities. The shift from patient to
student role was a very powerful one.
Implications: The process of rehabilitation should not just be understood in terms of
gaining skills, but in terms significant shifts in personal identity.
Supported Education
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4.
Hartley, M. T. (2010). Increasing resilience: Strategies for reducing dropout rates for
college students with psychiatric disabilities. American Journal of Psychiatric
Rehabilitation, 13(4), 295-315. doi:10.1080/15487768.2010.523372.
A review of the concept of resilience with suggestions for ways the concept could
strengthen existing SEd interventions, and improve retention in both 2 year and 4 year
college programs. They note common barriers to retention such as active symptoms, lack
of academic integration, and lack of supportive peer relationships, and suggest that
quality of resilience may distinguish between those who drop out and those who
complete post-secondary education.
Implications: Resilience-based approaches can facilitate protective factors such as
confidence for active coping, and skills for developing social support, which can
complement the core services of SEd of career planning: academic survival skills, and
connection to mental health supports.
5.
Mowbray, C. T., Megivern, D., & Holter, M. C. (2003). Supported education
programming for adults with psychiatric disabilities: Results from a national survey.
Psychiatric Rehabilitation Journal, 27(2), 159-167. doi:10.2975/27.2003.159.167.
A national (U.S.) survey describes the number and type of Supported Education
programs. They found that the most typical SEd program variation was provided within
Clubhouses, that a number of on-campus programs existed, and that there were a
smaller number of “freestanding” SEd programs. The article documented differences in
terms of budget, type of approach, and collaboration between mental health and
specialized educational personnel.
Implications: SEd can be provided in various ways. The evidence regarding the nature
and relative efficacy of these variations, and about what forms of collaboration is
necessary, is still emerging.
6.
Mowbray, C. T., Collins, M. E., Bellamy, C. D., Megivern, D. A., Bybee, D., &
Szilvagyi, S. (2005). Supported education for adults with psychiatric disabilities: An
innovation for social work and psychosocial rehabilitation practice. Social Work,
50(1), 7-20. Retrieved from http://www.naswpress.org/publications/journals/sw.html.
Mowbray, Collins et al. review the evolving SEd model and the accumulating evidencebase on its effectiveness. The core components include career planning, academic
survival skill building, and connection to services and resources, including academic
and mental health-related supports. They outline three prototype models: free-standing
classrooms, on-site, and the clubhouse model (which often provides support within the
clubhouse and within normalized academic settings on an outreach basis). Consistent
with psychosocial rehabilitation, the approach seeks to build relevant skills, create
supportive environments, and improve the fit between the student and his or her
environment. The review outlined the findings of several studies of SEd, one of which
was a randomized controlled trial, which showed an increase in enrolment in
postsecondary education to approximately 25%, compared to the control group’s rate of
approximately 5%. The other reviewed studies demonstrated increases in course
completion, and greater likelihood of reenrolment in the following academic year, but
Supported Education
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did not follow students up to assess degree completion. One study showed that students
typically were enrolled in two courses per term in two-year programs, which suggests
that, in terms of course load, the average SEd student profile is similar to that of the
typical part-time community college student. Another study showed that approximately
40% of students worked part-time while going to school, a rate that is lower than typical
part-time students, but higher than the general population of students with serious
mental illness. Some existing evidence suggests the typical SEd student is in their early
30’s, and is of low income. With respect to other outcomes, the Mowbray (2000) trial
found increased self-esteem, higher quality of life, and fewer social adjustment problems
in the experimental group. There is also some preliminary evidence that participants
may make significantly less use of hospital services. The authors of the present review
note that SEd is considered an “exemplary practice” by SAMSHA and note that more
evidence is needed to improve the intervention, to determine who can benefit most, and
in what settings the program is best implemented.
Implications: Supported Education is a promising approach that should be offered to
people who are interested in pursuing higher education, for its own benefits, and as a
way of improving vocational prospects. At this point, there is no reason to believe that
any one of the three variations of the model (clubhouse, free-standing, and on-site)
should be preferred.
Individual Trials
7.
Baksheev, G. N., Allott, K., Jackson, H. J., McGorry, P. D., & Killackey, E. (2012).
Predictors of vocational recovery among young people with first-episode psychosis:
Findings from a randomized controlled trial. Psychiatric Rehabilitation Journal, 35(6),
421-427. doi: 10.1037/h0094574
Objective: The current study sought to examine predictors of vocational recovery
(related to both educational and employment) among young people with first-episode
psychosis who participated in a randomized controlled trial (RCT). The analysis
investigated the IPS model for young adults, compared to treatment as usual with
approximately 20 people in each condition, using logistic regression analysis. The
analysis found that the main predictor of vocational recovery (defined as securing a
position in competitive employment or attending a course of education at any point
during the 6-month follow-up period) was participating in the IPS intervention.
Participants randomized to the vocational intervention were 16.26 times more likely to
obtain work or study during the follow-up period compared to participants randomized
to treatment as usual.
Implications: It is critical that vocational services are introduced as part of an evidencebased, multidisciplinary approach in routine clinical care at early psychosis services.
Further replication of these findings is indicated with a larger sample, looking at longer
term results. Cognitive remediation may enhance the outcomes, but this is an area for
furhter study.
Supported Education
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8.
Mowbray, C. (2000). The Michigan supported education program. Psychiatric
Services, 51(11), 1355-1357. doi: 10.1176/appi.ps.51.11.1355.
Mowbray reports on the results of an RCT trial on the Michigan Supported Education
Program. Participants were required to have completed or be near completion of high
school diploma (or GED), and have an interest in pursuing higher education. The
program is based on the model program developed at Boston University, provided in
three modules, and providing opportunities for students to learn and practice skills in
three areas: identifying vocational and educational goals, developing stress
management skills, and gaining academic survival skills. The format is a 2.5 hr
classroom-based preparatory course twice a week for six months. Students also receive
help in completing financial aid forms, college entrance application forms, registering
for courses, and are offered help in developing skills for common challenges, such as
negotiating with professors. The ultimate goal is to prepare participants for “readiness
for matriculation” at a two-year community college. Students in the control condition
were connected to a support worker, who at the student’s request was able to help with
self-defined problems. At the six and twelve month follow-up interviews, participants in
active treatment but not those in the control group showed significant improvements in
quality of life, self-esteem, and social adjustment and greater participation in college or
vocational training. Participants in the intervention group were nearly twice as likely to
be involved in school, employment, or both.
Implications: The Boston University model (upon which the Michigan SEd program is
based) appears to be a viable way of increasing enrolment in postsecondary education
and participation in vocational activities (or both). Improving retention and completion
rates for students participating in SEd, and factors affecting completion, are important
issues that requiring further consideration.
9.
Gutman, S. A., Kerner, R., Zombek, I., Dulek, J., & Ramsey, C. A. (2009). Supported
education for adults with psychiatric disabilities: Effectiveness of an occupational
therapy program. The American Journal of Occupational Therapy, 63(3), 245-254.
doi:10.5014/ajot.63.3.245.
Gutman, Kerner, Zomber, Duleck, and Ramsey reported the results of a trial on the
BRIDGE SEd program. Participants attended a two-hour on-campus preparatory class,
twice a week for six weeks. Topics of the class included study skills, orientation to
research skills, use of the computer/internet, and time management. 76% of participants
completed the program. At six-month follow-up, 10 of the 16 participants who
completed the program (63%) had enrolled in school, found a job, or were applying to a
specific program. Only 1 person from the 17 person control group had enrolled in
school.
Implications: Preparatory SEd oriented towards academic skills can improve enrolment
in post-secondary education. Retention and completion were not studied, and would
require ongoing support.
8.
Manthey, T. (2011). Using motivational interviewing to increase retention in
supported education. American Journal of Psychiatric Rehabilitation, 14(2), 120-136.
doi:10.1080/15487768.2011.569667.
Supported Education
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Manthey (2011) discusses the challenge of retention and post-secondary education
completion, in light of findings that between 25% to 50% of SEd students drop out prior
to completion, and those students supported through SEd often cycle through the
program a number of times before finally completing their education. They present a
case study illustrating efforts to incorporate Motivational Interviewing (MI) in order to
improve retention and completion rates. The rationale of the intervention is to help
participants maintain motivation (as opposed to using MI for initial engagement) and
work through ambivalence in the face of barriers to success, such as ambivalence to
disclosure, heavy workload, stigma experiences, and other challenges to motivation. The
case study illustrates how the education specialist can use active listening to help an
individual maintain motivation for staying in school after he has experienced an
unpleasant conflict in the classroom.
Implications: The “micro-skills” of education specialists (i.e., competency at active
listening using motivational approaches) may be integral to the ongoing support
component of SEd, and thus may be important in helping students pursue and complete
postsecondary education.
9.
Neuchterlein, K., H., Subotnik, K. L., Turner, L. R., Ventura, J., Becker, D. R., & Drake,
R. E. (2008). Individual placement and support for individuals with recent-onset
schizophrenia: Integrating supported education and supported employment.
Psychiatric Rehabilitation Journal, 31(4), 340-349. doi:10.2975/31.4.2008.340.349.
Neuchterlein et al. (2008) report on an adaptation of the Individual Placement and
Support (IPS) model for people with recent onset psychosis. Because the vocational
goals of such individuals often include returning to school, the IPS model was adapted
to include both Supported Employment (SE) and SEd, which entailed having the
employment specialist help place individuals in both educational and work settings.
Follow-along support included work with teachers, and aid in study skills and course
planning as well as traditional SE activities. Participants chose work, study, or both
work and study at equivalent rates. The control group received the brokered vocational
rehabilitation approach. The intervention group received a combination of IPS and Skills
Training (with the Workplace Fundamentals Module). Results have not yet been
published.
Implications: Rehabilitation workers should ascertain whether participants’ vocational
goals include education. If so, The IPS model appears to be a viable way of delivering
SEd.
10.
Robson, E., Waghorn, G., Sherring, J., & Morris, A. (2010). Preliminary outcomes from
an individualised supported education programme delivered by a community mental
health service. British Journal Of Occupational Therapy, 73(10), 481-486.
doi:10.4276/03082210X12865330218384.
Robson et al. (2010) report on the preliminary results of an evaluation of a supported
education program based on the IPS model, and implemented by occupational
therapists within a community mental health team in a rural area of Australia. The
Supported Education
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program followed 20 participants over an 18 month period and reported promising
results, with 70% either continuing with or completing their course of study.
Implications: This study further affirms the viability of the IPS model for improving
educational participation of young adults with serious mental illness. It also suggests the
viability of implementing this model within generic community mental health teams.
11.
Rudnick, A., & Gover, M. (2009). Combining supported education with supported
employment. Psychiatric Services, 60(12), 1690. doi:10.1176/appi.ps.60.12.1690.
Rudnick and Gover (2009) report on their evaluation of a combined supported
education/employment intervention. Phase One was a classroom-based preparatory
supported education (offering study skills, cognitive remediation, social skills training,
and computer skills); Phase Two offered supported education in a specific skilled
occupation, using group-based training provided by a skilled tradesperson, and also
offering life skills and counselling; and Phase Three included post-training supported
employment. The preliminary results show that nearly all participants concluded Phase
One, and approximately half had achieved competitive employment in their chosen
area.
Implications: Interventions combining SEd/SE for participants who wish to pursue
skilled trades appear viable, and appear to help these individual obtain competitive
employment. The final results of the study and other similar studies will provide more
information about the potential of these interventions, and about how to implement
them.
12.
Rudnick, A., McEwan, R. C., Pallaveshi, L., Wey, L., Lau, W., Alia, L., & Van
Volkenburg, L. (2013). Integrating supported education and supported employment
for people with mental illness: A pilot study. International Journal of Psychosocial
Rehabilitation, 18, 5-25.
This paper evaluated the first year of an innovative Canadian program (described in the
preceding reference) integrating supported employment with supported college
education for 37 college students with mental illness. The analysis used qualitative
methods, drawing on a purposive sample of 6 individuals, and 5 significant others.
Themes identified pre-project challenges and outcomes, related to the persepctives of
students, counsellors, and significant others. Pre-project challenges included being
overwhelmed by deadlines, presence of disability-related resources on campus, and
social alienation. Themes related to outcomes included confidence, coordination
between project leads and counsellors, increased social support, and some success at
finding employment.
Implications: The study illustrates promising early results suggesting that supported
education contributes to both educational and employment-related success.
Reviews of Supported Education in the context of Early Psychosis
Intervention
Supported Education
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13.
Bond, G. R., Drake, R. E., & Luciano, A. (2014). Employment and educational
outcomes in early intervention programmes for early psychosis: a systematic review.
Epidemiol Psychiatr Sci, 1-12. doi: 10.1017/s2045796014000419
The authors conducted a systematic review of employment/education outcomes for
early intervention programmes, including: (1) those providing evidence-based
supported employment, (2) those providing unspecified vocational services and (3)
those without vocational services. Of the twenty-seven studies, eleven evaluated early
intervention programmes providing supported employment. In eight studies that
reported employment outcomes separately from education outcomes, the employment
rate during follow-up for supported employment patients was 49%, compared with 29%
for patients receiving usual services. The two groups did not differ on enrolment in
education. Among studies with comparison groups, 7 of 11 (64%) reported significant
vocational/education outcomes favouring early intervention over usual services. In
summary, in early intervention programmes, supported employment moderately
increases employment rates but not rates of enrolment in education. These
improvements are in addition to the modest effects early programmes alone have on
vocational/educational outcomes compared with usual services.
Implications: While providing supported employment and education in an early
psychosis delivery context improves employment outcomes, more study is warranted of
the possibilities of improving educational outcomes for young adults.
14.
Killackey, E., & Allott, K. (2013). Utilising Individual Placement and Support to
address unemployment and low education rates among individuals with psychotic
disorders. Australian and New Zealand Journal of Psychiatry, 47(6), 521-523. doi:
10.1177/0004867413476755
These authors review the research on the IPS model related to educational and
employment outclomes, which includes a section on ealry psychosis. Including
education and employment as an outcome led to 85% (Killackey et al., 2008) and 83%
(Nuechterlein et al., 2008) of participants in IPS conditions in these trials enjoying a
successful vocational outcome. The authors also note the promise of including cognitive
remediation as part of the support package.
Implications: This review points to the promise of IPS supported emplyment and
education carried out in an early psychosis context.
Supported Education
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References – Supported Education
Baksheev, G. N., Allott, K., Jackson, H. J., McGorry, P. D., & Killackey, E. (2012). Predictors of
vocational recovery among young people with first-episode psychosis: Findings from
a randomized controlled trial. Psychiatric Rehabilitation Journal, 35(6), 421-427. doi:
10.1037/h0094574
Bond, G. R., Drake, R. E., & Luciano, A. (2014). Employment and educational outcomes in
early intervention programmes for early psychosis: a systematic review. Epidemiol
Psychiatr Sci, 1-12. doi: 10.1017/s2045796014000419
Gutman, S. A., Kerner, R., Zombek, I., Dulek, J., & Ramsey, C. A. (2009). Supported education
for adults with psychiatric disabilities: Effectiveness of an occupational therapy
program. The American Journal of Occupational Therapy, 63(3), 245-254.
doi:10.5014/ajot.63.3.245
Hartley, M. T. (2010). Increasing resilience: Strategies for reducing dropout rates for college
students with psychiatric disabilities. American Journal of Psychiatric Rehabilitation, 13(4),
295-315. doi:10.1080/15487768.2010.523372
Killackey, E., & Allott, K. (2013). Utilising Individual Placement and Support to address
unemployment and low education rates among individuals with psychotic disorders.
Australian and New Zealand Journal of Psychiatry, 47(6), 521-523. doi:
10.1177/0004867413476755
Mansbach-Kleinfeld, I., Sasson, R., Shvarts, S., & Grinshpoon, A. (2007). What education means
to People with psychiatric disabilities: A content analysis. American Journal of Psychiatric
Rehabilitation, 10(4), 301-316. doi:10.1080/15487760701680554
Manthey, T. (2011). Using motivational interviewing to increase retention in supported
education. American Journal of Psychiatric Rehabilitation, 14(2), 120-136.
doi:10.1080/15487768.2011.569667
Mowbray, C. (2000). The Michigan supported education program. Psychiatric Services, 51(11),
1355-1357. doi: 10.1176/appi.ps.51.11.1355
Mowbray, C. T., Megivern, D., & Holter, M. C. (2003). Supported education programming for
adults with psychiatric disabilities: Results from a national survey. Psychiatric
Rehabilitation Journal, 27(2), 159-167. doi:10.2975/27.2003.159.167
Mowbray, C. T., Collins, M. E., Bellamy, C. D., Megivern, D. A., Bybee, D., & Szilvagyi, S. (2005).
Supported education for adults with psychiatric disabilities: An innovation for social
work and psychosocial rehabilitation practice. Social Work, 50(1), 7-20. Retrieved from
http://www.naswpress.org/publications/journals/sw.html
Mueser, K. T., & Cook, J. A. (2012). Supported employment, supported education, and career
development. Psychiatric Rehabilitation Journal, 35(6), 417-420. doi: 10.1037/h0094573
Supported Education
Page
10
Neuchterlein, K., H., Subotnik, K. L., Turner, L. R., Ventura, J., Becker, D. R., & Drake, R. E.
(2008). Individual placement and support for individuals with recent-onset
schizophrenia: Integrating supported education and supported employment. Psychiatric
Rehabilitation Journal, 31(4), 340-349. doi:10.2975/31.4.2008.340.349
Robson, E., Waghorn, G., Sherring, J., & Morris, A. (2010). Preliminary outcomes from an
individualised supported education programme delivered by a community mental
health service. British Journal Of Occupational Therapy, 73(10), 481-486.
doi:10.4276/03082210X12865330218384
Rudnick, A., & Gover, M. (2009). Combining supported education with supported employment.
Psychiatric Services, 60(12), 1690. doi:10.1176/appi.ps.60.12.1690
Rudnick, A., McEwan, R. C., Pallaveshi, L., Wey, L., Lau, W., Alia, L., & Van Volkenburg, L.
(2013). Integrating supported education and supported employment for people with
mental illness: A pilot study. International Journal of Psychosocial Rehabilitation, 18,
5-25.
Storrie, K., Ahern, K., & Tuckett, A. (2010). A systematic review: Students with mental health
problems—A growing problem. International Journal of Nursing Practice,16(1), 1-6.
doi:10.1111/j.1440-172X.2009.01813.x
Supported Education
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Supported Employment
Qualitative Research
15.
Lexén, Annika, Hofgren, Caisa, & Bejerholm, Ulrika. (2013). Reclaiming the worker
role: Perceptions of people with mental illness participating in IPS. Scandinavian
Journal of Occupational Therapy, 20(1), 54-63. doi: doi:10.3109/11038128.2012.693946
Lexen et al. (2013) interviewed 14 IPS participants about their perceptions of working
and the relationship of the work environment on their work performance, using
questions from the Work Environment Impact Scale, and using content analysis. Work
was perceived as having a positive impact on their daily life, although starting work was
perceived as a challenge. The workers needed to develop personal strategies to manage
the impact of their mental illness in the work environment. Employer's support and the
social atmosphere among colleagues could be either supportive or detrimental to mental
health and work performance.
Implications: The study showed that it is vital to support the individual's own strategies
for adapting to the worker role when designing support, as well as to develop
collaborative relationships with employers.
16.
Dunn, E. C., Wewiorski, N. J., & Rogers, E. S. (2008). The meaning and importance of
employment to people in recovery from serious mental illness: Results of a
qualitative study. Psychiatric Rehabilitation Journal, 32(1), 59-62.
doi:10.2975/32.1.2008.59.62.
A recent qualitative study (Dunn, Wewiorski, & Rogers, 2008) interviewed 23 people
who were working and had achieved significant recovery for at least two years. This
study was part of a larger study on recovery conducted at Boston University. The
authors found that work had “personal meaning” for study participants and contributed
to their recovery. For employed people with mental illness, work represents a chance to
reclaim or affirm a valued sense of self. Returning to work contributed to recovery, first
of all, by enabling participants to gain a sense of esteem and status from others (and for
those employed in helping professions, to “give back”). Work also enabled study
participants to more effectively manage their illness, for instance by providing structure,
stimulation, and by helping them build social skills and avoid social isolation.
Implications: This study provides insight into why Supported Employment (SE) is
important to people with mental illness, and helps situate the body of research discussed
below in the wider context of recovery from mental illness.
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12
Seminal Studies
14.
Drake, R., Frey, W., Bond, G., Goldman, H., Salkever, D., Miller, A., . . . Milfort, R.
(2013). Assisting Social Security Disability Insurance Beneficiaries With
Schizophrenia, Bipolar Disorder, or Major Depression in Returning to Work.
American Journal of Psychiatry, 170(12), 1433-1441. doi:
doi:10.1176/appi.ajp.2013.13020214
The authors investigated the effectiveness of evidence-based supported employment for
people on disability benefits (including) who previously had typically been receiving
medication management only. The study population of this two-year study included
over 2000 people with schizophrenia, bipolar and major depression in 23 American
cities. This RCT tested a multifaceted intervention that entailed an integrated package of
support including supported employment, systematic medication management, and
other behavioral health services. At the same time, barriers to employment were
removed by providing complete health insurance coverage and suspending disability
reviews. The control group received usual services. Paid employment was the primary
outcome measure, and overall mental health and quality of life were secondary outcome
measures. The intervention group experienced more paid employment (60.3% compared
with 40.2%) and reported better mental health and quality of life than the control group.
Implications: Providing evidence-based supported employment to people receiving
medication-management only is feasible and effective in improving vocational and
mental health-related outcomes.
15.
Hoffmann, H., Jäckel, D., Glauser, S., Mueser, K., & Kupper, Z. (2014). Long-Term
Effectiveness of Supported Employment: 5-Year Follow-Up of a Randomized
Controlled Trial. American Journal of Psychiatry, 171(11), 1183-1190. doi:
doi:10.1176/appi.ajp.2014.13070857
Most IPS trials report two year outcomes. Using an RCT design, the authors of this trial
evaluated the longer-term employment and mental health impacts of the IPS model
compared with traditional vocational rehabilitation over 5 years, and also performed a
cost-benefit analysis. The study found that the beneficial effects of supported
employment on work at 2 years were sustained over the 5-year follow-up period.
Participants in supported employment were more likely to obtain competitive work
than those in traditional vocational rehabilitation (65% compared with 33%), worked
more hours and weeks, had higher wages, and longer job tenures. Reliance on
supported employment services for retaining jobs decreased from 2 years to 5 years.
Participants also ahd significantly fewer hospitalizations, had fewer psychiatric hospital
admissions, and spent fewer days in the hospital. The social return on investment was
higher for supported employment participants, defined as the ratio of work earnings to
vocational program costs, or as the ratio of work earnings to total vocational program
and mental health treatment costs.
Implications: The results demonstrate that the impacts of IPS an be sustained over time,
including employment outcomes, and mental health related outcomes. The social return
on investment is also superior to usual vocational services.
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16.
Mueser, K. T., Clark, R. E., Haines, M., Drake, R. E., McHugo, G. J., Bond, G. R.,
Swain, K. (2004). The Hartford study of supported employment for persons with
severe mental illness. Journal of Consulting and Clinical Psychology, 72(3), 479-490.
doi: 10.1037/0022-006X.72.3.479.
The Hartford study (Mueser, Clark et al., 2004) was part of the multisite U.S.
Employment Intervention Demonstration Program (EIDP) initiative. This study
compared Individual Placement and Support (IPS) to PSR and brokered vocational
rehabilitation, and showed that IPS achieved significantly better employment rates for
competitive employment (74% vs. 18% vs. 28%) and any employment (74% vs. 35& v
54)% during the study period; there was no difference on non vocational outcomes.
Implications: IPS can achieve successful vocational outcomes, and does not negatively
impact the clinical status of its participants, contrary to the previously held idea that the
stress of work would lead to higher rehospitalisation rates.
17.
Gold, P. B., Meisler, N., Santos, A. B., Carnemolla, M. A., Williams, O. H., & Keleher,
J. (2006). Randomized trial of supported employment integrated with assertive
community treatment for rural adults with severe mental illness. Schizophrenia
Bulletin, 32(2), 378-395. doi: 10.1093/schbul/sbi056.
The IPS model was implemented in the context of a rural ACT team in South Carolina
(another EIDP study), and compared to the typical approach using parallel vocational
and mental health services. This study (Gold et al., 2006) replicated the expected
superiority of the model (64% vs. 26% , a greater than 2:1 ratio in terms of employment
rates) and greater earnings (approximately $500/month median earnings vs. 0$ median).
Implications: The results show the feasibility of implementing the model, i.e.,
successfully integrating mental health and vocational rehabilitation supports, in a
context where these services are widely dispersed, and achieving superior employment
outcomes where job opportunities may be fewer and less diverse. The authors raise the
question of whether longer term economic self-sufficiency and career prospects will
require supported education and initial placement in jobs where participants can acquire
marketable, transferable skills.
18.
Haslett, W. R., Drake, R. E., Bond, G. R., Becker, D. R., & McHugo, G. J. (2011).
Individual placement and support: Does rurality matter? American Journal of
Psychiatric Rehabilitation, 14(3), 237-244. doi:10.1080/15487768.2011.598106.
A multi-site analysis (Haslett, Drake, Bond, Becker, & McHugo, 2011) looked at 87 IPS
programs, which they categorized as metropolitan, micropolitan, and small town, and
found little differences in employment rates.
Implications: Population density, and the factors associated with it (number and
diversity of employers, cultural norms, etc.) does not affect the ability of IPS programs to
achieve employment for their participants.
19.
Drake, R. E., McHugo, G. J., Bebout, R. R., Becker, D. R., Harris, M., Bond, G.R., &
Quimby, E. (1999). A randomized clinical trial of supported employment for inner-
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city patients with severe mental disorders. Archives of General Psychiatry, 56(7), 627633. doi: 10.1001/archpsyc.56.7.627.
Drake, McHugo et al. (1999) compared IPS to “enhanced vocational rehabilitation” for
inner city participants using a transitional “stepwise” approach using parallel vocational
rehabilitation services, and found superior outcomes on employment rates (61% vs. 9%),
on the likelihood of working over 20 hrs (50% vs. 5%) use of sheltered employment (11%
vs. 71%), and found no differences in job satisfaction, and on non-vocational outcomes
(self-esteem, quality of life, symptoms, hospitalization). Higher cumulative amounts of
vocational services were associated with better employment outcomes; higher
cumulative amounts of clinical services were associated with worse employment
outcomes.
Implications: The study shows that the IPS model can be successfully implemented in
an American inner city, and that participants with “multiple challenges” in these
settings can gain the benefits of SE experienced by participants in other study settings.
The study raises the question, however, of how outcomes such as job satisfaction and
improvements in quality of life could be achieved. 17.
Cook, J. A., Leff, H. S.,
Blyler, C. R., Gold, P. B., Goldberg, R. W., Mueser, K. T., . . . Burke-Miller, J. (2005).
Results of a multisite randomized trial of supported employment interventions for
individuals with severe mental illness. Archives of General Psychiatry, 62(5), 505-512.
doi:10.1001/archpsyc.62.5.505.
An article on a seminal multi-site study (Cook, Leff et al., 2005), reported the cross-site
findings of the EIDP, which compared “highly integrated” psychiatric and vocational
supported employment programs to services as usual, finding that across the seven
study sites the intervention group achieved over twice the employment rates, and were
1.5 times as likely to work 40 hrs/month, when demographic, work history and clinical
confounds were taken into consideration.
Implications: This American study showed that SE can successfully be implemented
and achieve successful employment-related results across a broad array of settings.
20.
Cook, J. A., Blyler, C. R., Leff, H. S., McFarlane, W. R., Goldberg, R. W., Gold, P. B., . . .
Razzano, L. A. (2008). The employment intervention demonstration program: Major
findings and policy implications. Psychiatric Rehabilitation Journal, 31(4), 291-295.
doi: 10.2975/31.4.2008.291.295.
A follow-up article on the EIDP (Cook, Blyler et al., 2008) reiterates the main findings,
which suggest that various forms of SE (not just IPS, but all of those using the critical
ingredients -- focus on competitive employment, close integration of vocational and
mental health services, services based on consumer preference/desire to work rather
than “readiness”, rapid job search using job development strategies, and ongoing
support) achieve better employment outcomes than “treatment as usual”, and presents
subsequent evidence suggesting that the job development aspect of the model has
relatively more support than the ongoing support function. They quote results that were
somewhat lower than other studies (55% vs. 34% employed), but show that employment
outcomes improved over time. Those individuals offered job development were five
times more likely to obtain competitive employment, and individuals with no prior
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work history had almost no chance of obtaining competitive employment without job
development.
Implications: Various forms of SE (including modified “family-aided” Assertive
Community Treatment (ACT), where the employment specialist was integrated into the
ACT team that was linked with a local employment consortium, and EARNS, i.e. an SE
model which developed a natural support network supporting the individuals’ job
aspirations) can achieve competitive employment outcomes. Job development, “a
collection of activities which match or tailor particular jobs to particular clients” is the
“lynchpin” element of the SE model. The review (a multi-site “effectiveness” trial) also
shows that the intervention can achieve its effects even in “real world” settings.
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Review Articles
Note: for a full description of the SE model, see the “critical ingredients” section below.
22.
Marshall, T., Goldberg, R. W., Braude, L., Dougherty, R. H., Daniels, A. S., Ghose, S.
S., . . . Delphin-Rittmon, M. E. (2014). Supported employment: assessing the evidence.
Psychiatric Services (Washington, D.C.), 65(1), 16-23. doi: 10.1176/appi.ps.201300262
The authors reviewed meta-analyses, research reviews, and individual studies from 1995
through 2012, assessing the overall level of evidence for effectiveness. They graded the
level of evidence for IPS supported employment as high, based on 12 systematic reviews
and 17 randomized controlled trials of the model. Supported employment consistently
demonstrated positive outcomes, including higher rates of competitive employment,
less time taken finding a first competitive job, more hours and weeks worked, and
higher wages. There was also strong evidence supporting the effectiveness of individual
elements of the model.
Implications: The substantial evidence base suggests that policy makers should include
it as part of routinely delivered mental health care. More study is needed to establish
the longer-term effectiveness of the model, as well as its impact on groups such as young
adults and people from various ethnocultural backgrounds.
23.
Twamley, E. W., Jeste, D. V., & Lehman, A. F. (2003). Vocational rehabilitation in
schizophrenia and other psychotic disorders: A literature review and meta-analysis of
randomized controlled trials. The Journal of Nervous and Mental Disease, 191(8), 515523. doi:10.1097/01.nmd.0000082213.42509.69.
An early review (Twamley, Jeste, & Lehman, 2003) of 11 published RCT studies, 9 of IPS,
5 of which compared SE to traditional vocational rehabilitation, showed a 51 to 18%
advantage in terms of competitive employment rates.
Implications: The authors suggest that this effect size be used as a benchmark for
comparison in future trials.
24.
Moll, S., Huff, J., & Detwiler, L. (2003). Supported employment: Evidence for a best
practice model in psychosocial rehabilitation. The Canadian Journal of Occupational
Therapy, 70(5), 298-310. Retrived from http://www.caot.ca/default.asp?pageid=6.
A Canadian review (Moll, Huff, & Detwiler, 2003) showed similar results, and discusses
the practice implications of this evidence for occupational therapists. They point to a
number of implementation challenges that should be considered, such as anticipating
possible reasons why clients may have their jobs terminated (e.g., interpersonal conflicts,
illness management challenges, job satisfaction), and anticipating the length of time
needed for high fidelity implementation, citing evidence that a minimum of one year is
necessary to restructure services and help build appropriate skills in professionals.
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Implications: The authors argue that occupational therapists are uniquely positioned to
deliver the IPS model given their skills in individualized assessment and occupational
analysis, which would contribute to the process of job development and follow-along
supports. However, OT’s may have to shift their traditional focus on assessment and
skill building towards identifying and developing supports in the work environment,
and networking with potential employers. OT’s can act as change agents, building
support for service change amongst other potential champions, and helping to develop a
common vision of the model needed for success.
25.
Bond, G. R. (2008). An update on randomized controlled trials of evidence-based
supported employment. Psychiatric Rehabilitation Journal, 31(4), 280-290.
doi:10.2975/31.4.2008.280.290.
A more recent “review update” (Bond, 2008) unlike the Cook, Leff et al. (2005) EIDP
multi-site study, was limited to “high fidelity” IPS programs, for instance excluding
studies where the job specialist was integrated within an ACT team, and found higher
employment rates as compared to traditional programs (nearly a 3:1 ratio vs. an app. 2:1
ratio). Although the paper also noted that while SE programs found jobs more quickly,
on average participants took five months to find their first job. It also noted that most
participants work part-time, and duration of employment after the first job was
approximately half a year. Employment outcomes do appear to hold over the longer
term; for instance, a ten-year follow-up study showed that nearly 50% of participants
were working and had worked at least five years during that period. The paper also
reviewed recent research suggesting that the IPS model could be enhanced by
addressing social cognitive deficits, and by using motivational interventions, and that it
would benefit people with recent onset psychosis.
Implications: The robustness of the findings appears greater when comparing high
fidelity IPS (rather than SE in general) to traditional interventions. Enhancements of the
IPS model are desirable and feasible for people with (social) cognitive deficits, and for
those experiencing recent-onset psychosis (see “critical ingredients” section below).
26.
Crowther, R., Marshall, M., Bond, G. R., & Huxley, P. (2001). Vocational rehabilitation
for people with severe mental illness. Cochrane Database of Systematic Reviews. doi:
10.1002/14651858.CD003080.
A Cochrane review (Crowther, Marshall, Bond, & Huxley, 2010) compared traditional
pre-vocational training approaches against supported employment (including IPS),
finding that the latter achieved greater employment outcomes at all time periods (e.g.
36% vs. 12% were employed at 12 months), earned more and worked more weeks than
participants in traditional approaches (clubhouses and other transitional employment
interventions), which fared no better than standard community care on employmentrelated outcomes. The review was unable to conclude that SE achieved non-vocational
outcomes (symptom reduction, self esteem and quality of life improvements) for the
intervention groups, but suggested that these in fact were seen in the intervention group
participants who actually had found and kept jobs (approximately 63% of the
intervention group was not working when these outcomes were measured for). The
authors conclude that there was no evidence that researchers “cherry picked” clients
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more likely to be employed and included good recruitment of women and ethnic
minorities, and thus that the review’s results are generalizable to the wider population
of people with serious mental illness. However, with the exception of one trial, all
studies were conducted in the United States. Generalizability to countries with “less
dynamic” economies, different welfare systems, and culturally dissimilar attitudes
towards work may thus be in question.
Implications: Because SE, including IPS programs, are only sparsely available, these
results suggest that policy-makers and funders in all countries, including Canada, make
a concerted effort to help agencies and clinicians implement these interventions more
widely. More study is needed regarding the costs and cost-effectiveness of these
interventions, though there is some indication that the costs may be equivalent to
traditional programs.
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Generalizability of the IPS Model to Non-U.S. Contexts (Canada, Europe)
27.
Bond, G. R., Drake, R. E., & Becker, D. R. (2012). Generalizability of the Individual
Placement and Support (IPS) model of supported employment outside the US. World
Psychiatry, 11(1), 32-39.
While reviews of controlled studies of the IPS model of supported employment have
documented its effectiveness in the US, its generalizability to other countries has not
been systematically evaluated. This is the first review to compare US to non-US studies.
The authors identified 15 randomized controlled trials of IPS programs, 9 in the US and
6 outside the US. They examined competitive employment outcomes, including
employment rate, days to first job, weeks worked during follow-up, and hours worked,
as well as other outcomes such as non competitive employment, program retention and
nonvocational outcomes. They found that IPS programs had significantly better
outcomes across a range of competitive employment indicators and higher retention in
services than control groups. The overall competitive employment rate for IPS clients in
US studies was significantly higher than in non-US studies (62% vs. 47%).
Implications: The consistently positive competitive employment outcomes strongly
favoring IPS over a range of comparison programs suggests that IPS transports well into
new settings. Transporting IPS into other jurisdictions requires study about how it can
be adapted in a way that maintains fidelity to the model.
28.
Bejerholm, U., Areberg, C., Hofgren, C., Sandlund, M., & Rinaldi, M. (2015).
Individual Placement and Support in Sweden—A randomized controlled trial. Nordic
Journal of Psychiatry, 69(1), 57-66. doi: doi:10.3109/08039488.2014.929739
The authors conducted a randomized controlled trial comparing IPS to traditional
Swedish vocational rehabilitation (TVR) services, involving 120 participants. They
found tthat IPS participants gained employment five times quicker than those in TVR.
Ninety per cent of the IPS participants became involved in mainstream settings,
including work, internships or education, while 24% in the TVR group achieved this.
Using internships tended to delay the time to first employment.
Implications: IPS can be implemented and is effective in a Swedish context.
29.
Michon, H., van Busschbach, J. T., Stant, A. D., van Vugt, M. D., van Weeghel, J., &
Kroon, H. (2014). Effectiveness of individual placement and support for people with
severe mental illness in The Netherlands: a 30-month randomized controlled trial.
Psychiatr Rehabil J, 37(2), 129-136. doi: 10.1037/prj0000061
The aim of this study was to examine the effectiveness of IPS in the Dutch
socioeconomic context, using a multisite randomized controlled trial, involving 151
persons expressing an explicit wish for regular employment, comparing IPS with
traditional vocational rehabilitation (TVR). The study found that in 30 months, 44% of
IPS participants obtained competitive work, compared with 25% of participants
supported by TVR. No direct effect of IPS on mental health, self-esteem or quality of life
was found. Being competitively employed before follow-up measurements was
significantly associated with an increase in mental health, self-esteem and quality of life.
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Implications: This study suggests that IPS can work in countries such as the
Netherlands with "protective" social safety nets which can inadvertently pose employent
barriers to people with serious mental illness.
30.
Oshima, I., Sono, T., Bond, G. R., Nishio, M., & Ito, J. (2014). A randomized controlled
trial of individual placement and support in Japan. Psychiatric Rehabilitation Journal,
37(2), 137-143. doi: 10.1037/prj0000085
The authors sought to evaluate whether IPS could be implemented with success in
Japan., using a randomized controlled trial using a 6-month follow-up, and randomizing
37 participants to either IPS or conventional vocational services, evaluating competitive
employment rates, hours and weeks worked, and wages earned. The study found that
IPS participants were more likely to work competitively (44.4% v. 10.5%) work more
hours (168 v. 41 ), and work more weeks (6.4 v. 1.8).
Implications: IPS can be implemented in Japan and yield better competitive
employment outcomes than conventional vocational services.
31.
Waghorn, G., Dias, S., Gladman, B., Harris, M., & Saha, S. (2014). A multi-site
randomised controlled trial of evidence-based supported employment for adults with
severe and persistent mental illness. Australian Occupational Therapy Journal, 61(6),
424-436. doi: 10.1111/1440-1630.12148
The aim of the current trial was to assess the effectiveness of evidence-based supported
employment in Australia, using a four-site RCT, involving 208 participants, comparing
RCT with other disability employment services in the local area. The study found that at
12 months, those in the IPS condition were 2.4 times more likely to start employment
than those receiving usual support (42.5% vs. 23.5%). There were no differences amongst
employed paricipants in either group related to job duration, hours worked, or job
diversity. Attrition was higher than expected in both conditions with nearly 30%
completing the baseline interview but not taking part in the study.
Implications: The results suggest that IPS supported employment is more effective
than non-integrated supported employment in Australia. As in many other
international studies the relative impact of IPS is similar to US studies, but the
employment rates in both groups are lower.
32.
Latimer, E. A., Lecomte, T., Becker, D. R., Drake, R. E., Duclos, I., Piat, M., . . . Xie, H.
(2006). Generalisability of the individual placement and support model of supported
employment: results of a Canadian randomised controlled trial. The British Journal of
Psychiatry, 189(1), 65-73. doi:10.1192/bjp.bp.105.012641.
A group of Canadian researchers (Latimer et al., 2006) successfully implemented the
model in Quebec, recruiting participants who weren’t currently employed and wanted
to work, and compared it to traditional vocational rehabilitation, showing superior
employment rates (48% vs. 18%) and more hours worked for those employed (126 vs. 71
hrs/week).
Implications: The IPS model can successfully be implemented in program and system
contexts that are very different from where they were initially implemented in the US. In
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Canada, the model’s generalizabilty to Aboriginal people and various ethnocultural
groups remains in question.
33.
Corbière, M., Lanctôt, N., Lecomte, T., Latimer, E., Goering, P., Kirsh, B., . . .
Kamagiannis, T. (2010). A pan-Canadian evaluation of supported employment
programs dedicated to people with severe mental disorders. Community Mental
Health Journal, 46(1), 44-55. doi: 10.1007/s10597-009-9207-6.
A more recent Canadian paper (Corbière et al., 2010) looked at implementation of SE in
26 programs across three provinces. They found several distinct patterns of
implementation. One key challenge was integrating mental health and vocational
practice. The authors suggest this may have been exacerbated particularly in rural
settings where the two components were less likely to be co-located. Employment
specialists may also feel reluctant to participate in traditional mental health case
conferences based on the medical model rather than rehabilitative paradigm, and may
have felt their knowledge was undervalued.
Implications: Achieving fidelity requires striving to achieve a shared interdisciplinary
vision of practice.
34.
Oldman, J., Thomson, L., Calsaferri, K., Luke, A., & Bond, G.R. (2005). A case report of
the conversion of sheltered employment to evidence-based supported employment in
Canada. Psychiatric Services, 56(11), 1436 - . doi: 10.1176/appi.ps.56.11.1436.
A Canadian case study (Oldman et al., 2005) documented the evolution of supported
employment services within a community mental health agency in Vancouver, BC,
which shifted from providing to providing sheltered employment, to pre-employment
training, to using brokered employment services, and finally to fully implementing the
IPS model (moving its vocational rehabilitation counsellors into external mental health
teams. This change occurred over a period of several years and required organizational
leadership and a commitment to quality assurance. By implementing IPS, employment
rates went from 3, to 15, and finally to 50%.
Implications: With organizational leadership, Canadian community agencies can work
with other formal services (e.g. case management teams) to effectively implement
evidence-based supported employment.
35.
Burns, T., & Catty, J. (2008). IPS in Europe: The EQOLISE trial. Psychiatric
Rehabilitation Journal, 31(4), 313-317. doi: 10.2975/31.4.2008.313.317.
Authors from a multi-site research team (Burns & Catty, 2008) report on the results of
the EQOLISE study, a multi-site European trial showed that across the six centres, IPS
doubled the employment outcomes (e.g. 54% vs. 27% worked for “at least one day”) and
the probability of hospital readmission declined. The variability in employment
outcomes was partially explained by local employment rates and welfare system
regulations.
Implications: The IPS model can be successfully implemented in Europe, and it can be
effective even when achieving positive outcomes are hindered by local employment
conditions.
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Non-Vocational Outcomes
36.
Luciano, A., Bond, G., & Drake, R. (2014). Does employment alter the course and
outcome of schizophrenia and other severe mental illnesses? A systematic review of
longitudinal research. Schizophrenia Research, 159(2-3), 312-321.
This study is the only systematic review which looks at the relationship between
employment and course of serious mental illness. The review included 12 analyses
representing eight cohorts, or nearly 7000 participants, finding that employment was
consistently associated with reductions in outpatient psychiatric treatment as well as
improved self-esteem. Some recent studies have associated employment with positive
outcomes in several other areas, including symptom severity, psychiatric
hospitalization, life satisfaction, and global wellbeing. People with serious mental
illness who become steady workers, whether through IPS or otherwise, generally show
some health benefits, such as greater control over psychiatric symptoms. At the same
time, employment was consistently unrelated to worsening outcomes.
Implications: achieving employment does not cause harm among people with severe
mental illnesses. More sophisticated analyses of long-term follow-up studies are needed
to clarify the nature of associations between employment and its possible benefits.
37.
Bond, G. R., Resnick, S. G., Drake, R. E., Xie, H., McHugo, G. J., & Bebout, R. R.
(2001). Does competitive employment improve nonvocational outcomes for people
with severe mental illness? Journal of Consulting and Clinical Psychology, 69(3), 489501. doi:10.1037/0022-006X.69.3.489.
An important early paper (Bond, Resnick et al., 2001) studied non-vocational outcomes
(symptoms, self-esteem, quality of life) in participants receiving various forms of
vocational rehabilitation and work situation (competitive, sheltered, minimal work, and
no work), finding in the competitively employed compared to minimal-low employed
participants higher rates of improvements in symptoms, higher self-esteem, and higher
rates of satisfaction with employment, finances and leisure time. These advantages were
not found in the sheltered employment group.
Implications: While earlier studies had showed no negative impact on non-vocational
outcomes (e.g., symptoms, hospitalization), practitioners and policy-makers can
anticipate positive mental health-related changes in conjunction with the improved
vocational outcomes resulting from SE.
Predictors of Success
38.
Corbière, M., Brouwers, E., Lanctot, N., & van Weeghel, J. (2014). Employment
specialist competencies for supported employment programs. J Occup Rehabil, 24(3),
484-497. doi: 10.1007/s10926-013-9482-5
Significant variations in individuals' vocational success may be partly explained by
differences in employment specialists' competencies. This study sought to measure
competencies (behaviors, attitudes and knowledge) of Canadian and Dutch supported
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employment program staff and link these to employment outcomes. Over 150
employment specialists working in Canadian and Dutch supported employment
programs completed the Behaviors, Attitudes, and Knowledge in Employment
Specialists (BAKES) questionnaire and provided information about their clients'
vocational outcomes. The analysis found that the two most useful subscales for
predicting vocational success were: (1) Relationships with employers and supervisors,
and (2) support and client-centered approach.
Implications: validating the BAKES will better define the broad range of competencies
necessary for employment specialists. Improved knowledge of these comptencies may
facilitate training and recruitment of this position, which can facilitate improved
employment outcomes.
39.
Bond, G. R., Becker, D. R., & Drake, R. E. (2011). Measurement of Fidelity of
Implementation of Evidence-Based Practices: Case Example of the IPS Fidelity Scale.
Clinical Psychology: Science and Practice, 18(2), 126-141. doi: 10.1111/j.14682850.2011.01244.x
Nine of 10 studies assessing the predictive validity of the IPS fidelity scale found
positive associations with employment outcomes. Its use in quality improvement was
supported by positive reports from seven multisite projects.
Implications: use of the IPS fidelity scale helps assure successful implementation of
supported employment, which contributes to positive employment outcomes.
40.
Campbell, K., Bond, G. R., & Drake, R. E. (2011). Who benefits from supported
employment: A meta-analytic study. Schizophrenia Bulletin, 37(2), 370-380.
doi:10.1093/schbul/sbp066.
A paper entitled “Who Benefits from IPS” showed that all groups studied, by clinical,
demographic and work history variables, favoured IPS on job acquisition, weeks
worked, and job tenure outcomes (Campbell, Bond, & Drake, 2011).
Implications: IPS can still benefit clients having characteristics considered to be
employment barriers (little work history, symptomatic, etc.). Compared to program
factors, individual-level factors are not strong predictors of success, and can be
ameliorated by SE.
41.
Mueser, K. T., Campbell, K., & Drake, R. E. (2011). The effectiveness of supported
employment in people with dual disorders. Journal of Dual Diagnosis, 7(1-2), 90-102.
doi: 10.1080/15504263.2011.568360.
A paper by (Mueser, Campbell, & Drake, 2011) focussing on participants from
previously reviewed studies having recent substance use, showed that compared to
traditional vocational rehabilitation interventions, the IPS intervention benefitted these
participants in similar ways from the overall group, in relation to how quickly a first job
was obtained, and in terms of wages, and hours and weeks worked during the study
period.
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Implications: Substance use should not be a barrier to eligibility to SE services.
42.
Catty, J., Lissouba, P., White, S., Becker, T., Drake, R.E., Fioritti, A., . . . Burns, T.
(2008). Predictors of employment for people with severe mental illness: Results of an
international six-centre randomised controlled trial. The British Journal of Psychiatry,
192(3), 224-231. doi:10.1192/bjp.bp.107.041475.
Catty et al. (2008) reported on a study looking at success factors (individual, process and
service-level characteristics) associated with the superior employment outcomes found
in the EQOLISE study, a multi-centre RCT of IPS conducted in six European sites.
Having a previous work history, fewer unmet social needs and a better relationship with
vocational workers predicted better employment outcomes. Remission of symptoms and
swifter service uptake were associated with working more. Having a service closer to
the IPS model was the only service characteristic associated with the models’
effectiveness.
Implications: Achieving successful results requires achieving high fidelity
implementation of IPS and targeting relational skills.
43.
Tsang, A. W. K., Ng, R. M. K., & Yip, K. C. (2010). A six-month prospective casecontrolled study on the effects of the clubhouse rehabilitation model on Chinese
patients with chronic schizophrenia. East Asian Archives Of Psychiatry, 20(1), 23-30.
Retrieved from http://easap.asia/index.htm.
Tsang, Ng, and Yip (2010) a study on predictors of employment outcomes, showed
overwhelmingly (contrary to previous results) that cognitive functioning was a
significant predictor, as well as identifying other predictors including negative
symptoms, education, previously holding a job successfully, age, social skills and
support, and rehabilitation support to restore community functioning. The review found
that hospitalization, positive symptoms and substance abuse were not significant
predictors. Other potential predictors that may be changeable and related to recovery
include concerns regarding benefit status, negative/self-stigmatizing beliefs, and social
skills deficits.
Implications: This study suggests that evidence-based employment programs may be
enhanced by developing strategies to help participants address cognitive and social
functioning; it also suggests that psychosocial rehab strategies in general, while not
sufficient in themselves to achieve employment outcomes, may enhance SE programs.
Innovations and Future Evolution of Supported Employment
44.
Mueser, K. T., & McGurk, S. R. (2014). Supported employment for persons with
serious mental illness: current status and future directions. Encephale, 40 Suppl 2, S4556. doi: 10.1016/j.encep.2014.04.008
Supported employment has achieved successful results in a wide range of cultural and
clinical populations. A pressing future need is to improve implementation to ensure the
high fidelity programming necessary to achieve these results, through the use of
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standardized and tested models of training and consultation. Another need is to
increase the effectiveness of supported employment for clients who have not
traditionally benefited (e.g. people with cognitive deficits). Efforts are underway to
increase the efficiency of training methods, and to improve its effectiveness for those
clients who do not benefit.
Implications: future directions for the field include making greater use of existing
evidence-informed strategies for implementation, improving implemention strategies,
and improving the model's effectiveness for people who have traditionally benefitted
less.
45.
Bell, M. D., Choi, K.-H., Dyer, C., & Wexler, B. E. (2014). Benefits of cognitive
remediation and supported employment for schizophrenia patients with poor
community functioning. Psychiatric Services, 65(4), 469-475.
This study sought to determine whether augmenting supported employment with
cognitive remediation can improve vocational outcomes and whether augmentation is
more important for participants with lower community functioning, using a secondary
analysis of data from two trials, which separated participants by level of community
functioning, and comparing employment results according to whether or not the groups
received cognitive remediation. The reults showed that employment rates over two
years for participants with lower community functioning were significantly different for
the two conditions (supported employment = 20%, plus cognitive remediation = 49%),
whereas participants with higher functioning showed equivalent rates of employment
(62% versus 54%, ns). Among lower-functioning participants, those who received
cognitive remediation also worked significantly more hours over two years than those
who received supported employment only, but higher-functioning participants worked
similar amounts of hours in both conditions. Improvements in cognitive functioning and
intrinsic motivation were related to employment outcomes but only for the lowerfunctioning group in the supported employment plus cognitive remediation condition,
suggesting possible mechanisms for the observed effects.
Implications: Augmenting supported employment with cognitive remediation may
boost vocational outcomes for participants with lower community functioning but may
not be necessary for those functioning better in their communities.
46.
Kern, R. S., Zarate, R., Glynn, S. M., Turner, L. R., Smith, K. M., Mitchell, S. S., . . .
Liberman, R. P. (2013). A demonstration project involving peers as providers of
evidence-based, supported employment services. Psychiatr Rehabil J, 36(2), 99-107.
doi: 10.1037/h0094987
The article describes a demonstration project to train recovering peer advocates how to
provide evidence-based supported employment services, and to examine the
relationship between competence and employment outcome. A training curriculum was
developed to teach the core competencies of the Individual Placement and Support (IPS)
model of supported employment. Peer competency was assessed using a formal IPS
fidelity review performed by two external reviewers and using the Kansas Employment
Specialist Job Performance Evaluation. Program efficacy was assessed by examining the
number of job placements and corresponding tenure. The fidelity review found that
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peers met IPS standards of implementation on half of the service delivery items, and that
attitudes were a relative strength; job performance competency ratings fell in the
average to above average range across the skill areas assessed (e.g., vocational
assessment, job development). Thirty-three percent of consumers from the peers'
caseloads got competitive jobs; mean tenure was 26 weeks.
Implications: This demonstration project provides a starting point for future efforts
aimed at expanding the role of peers as providers of evidence-based mental health
services and provides some optimism that this is a realistic goal.
47.
Lord, S. E., McGurk, S. R., Nicholson, J., Carpenter-Song, E. A., Tauscher, J. S., Becker,
D. R., . . . Bond, G. R. (2014). The potential of technology for enhancing individual
placement and support supported employment. Psychiatr Rehabil J, 37(2), 99-106. doi:
10.1037/prj0000070
This study describes how technolog may enhance delivery of IPS supported
employment. Mobile and cloud technologies open opportunities for collaboration of
support, self-directed care, and ongoing support to help clients obtain and maintain
meaningful employment.
Implications: innovation and research is needed to evaluate efficacy of technologybased approaches for increasing the efficiency of the IPS model and exanding its reach.
48.
Lecomte, T., Corbière, M., & Lysaker, P. H. (2014). A group cognitive behavioral
intervention for people registered in supported employment programs: CBT-SE.
L'Encephale, 40 Suppl 2, S81-90. doi: 10.1016/j.encep.2014.04.005
This article presents some preliminary data on a trial of a novel group-based CBT
intervention to facilitate job tenure by addressing dysfuntional beliefs about one's
abilities for finding and keeping work, using using a one-month 8-session program. The
intervention teaches work-specific skills such as managing one's stressors at work,
problem-solving, recognizing one's strengths and qualities as a worker, dealing with
criticism, using positive assertiveness, negotiating work accommodations and
overcoming stigma.
In terms of work outcomes, 50 % of all participants in both conditions found competitive
work. Out of those working competitively, the number of participants working more
than 24 hours per week at the 12-month follow-up was higher in the CBT-SE group
compared to the control condition (75 % vs. 50 %). Similarly, there was a trend towards
the number of consecutive weeks worked at the same job being slightly superior at the
12-month follow-up for those who had received the CBT-SE intervention (22.5 weeks vs.
18.3 weeks).
Implications: preliminary data suggest that the CBT-SE intervention might help people
with severe mental illness use skills and gain the needed confidence enabling them to
work longer hours and consecutive weeks. These results should be considered with
caution given that only 24 participants were looked at whereas the final sample size will
be of 160 participants.
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49.
Corbière, M., Villotti, P., Lecomte, T., Bond, G. R., Lesage, A., & Goldner, E. M. (2014).
Work accommodations and natural supports for maintaining employment.
Psychiatric Rehabilitation Journal, 37(2), 90-98.
This authors developed and validated a new measure to describe work accommodations
and natural supports available in the workplace. The study also sought to determine
which of these are significantly related to job tenure for participants enrolled in
supported employment services. In total, 124 people with a severe mental disorder
enrolled in supported employment programs and who had successfully retained a
competitive job at the 9-month follow-up answered the Work Accommodation and
Natural Support Scale (WANSS). They also provided information regarding their
disclosure strategies in the workplace and the length of their job tenure. The results
showed that disclosure was significantly related to the number of work accommodations
and natural supports available in the workplace. Supervisor and coworker supports in
particular predicted job tenure.
Implications: Disclosure can help build natural support in the workplace, which
employment specialists can measure using a valid and useful scale, the WANSS.
50.
Drake, R. E., & Bond, G. R. (2008). The future of supported employment for people
with severe mental illness. Psychiatric Rehabilitation Journal, 31(4), 367-376. doi:
10.2975/31.4.2008.367.376.
Drake and Bond (2008) discuss the future evolution of the model, suggesting that future
issues will include: being more systematic about implementation, addressing disabilityrelated policies, more focus on job development and ongoing job support, career
development, individualizing the SE model for people with motivation challenges and
illness-related barriers (e.g. cognitive deficits), and expanding the model to new
populations (e.g. early psychosis, people who have experienced homelessness).
51.
McGurk, S. R., Mueser, K. T., & Pascaris, A. (2005). Cognitive training and supported
employment for persons with severe mental illness: One-year results from a
randomized controlled trial. Schizophrenia Bulletin, 31(4), 898-909.
doi:10.1093/schbul/sbi037.
McGurk, Mueser, and Pascaris (2005) describe the Thinking Skills for Work intervention,
for addressing cognitive impairments that pose employment barriers, and present
results of an RCT trial showing the intervention to improve employment outcomes
(likeliness to work, hours/weeks worked, wages earned) for people with cognitive
deficits (n = 44) compared to usual IPS.
Implications: The study demonstrates the feasibility of integrating cognitive
remediation into IPS, and paves the way for more research into its efficacy and
generalizability to other settings.
52.
Roberts, M. M., Murphy, A., Dolce, J., Spagnolo, A., Gill, K., Lu, W., & Librera, L.
(2010). A study of the impact of social support development on job acquisition and
retention among people with psychiatric disabilities. Journal of Vocational
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Rehabilitation, 33(3), 203-207. Retrieved from http://www.iospress.nl/journal/journalof-vocational-rehabilitation/.
Roberts et al. (2010) report on the results of a study which examined the impact on SE
outcomes of an approach to social network development known as Person Centered
Planning (PCP). The study included participants from seven eligible SE programs in the
Northeastern United States, who reported results at the 12 month mark. The authors
found a positive relationship between the number of non-paid support network
members, and job retention (number of days worked over the course of the study). They
found a negative relationship between number of paid workers in the network and job
retention. There was also a positive relationship between the quality of implementation
of PCP (as measured by quality indicators) and number of days worked.
Implications: Strengthening natural support networks may improve long-term job
retention for SE participants. The mechanism by which increased natural support
translates into better job retention (or increased number of paid supporters is associated
with relatively lower job retention) remains an interesting question to be investigated.
Adapting SE for Early Psychosis
53.
Abdel-Baki, A., Létourneau, G., Morin, C., & Ng, A. (2013). Resumption of work or
studies after first-episode psychosis: the impact of vocational case management. Early
Intervention in Psychiatry, 7(4), 391-398. doi: 10.1111/eip.12021
This descriptive study focused on occupational status of an early psychosis cohort
during the first 5 years of Vocational Case Management. 68% held a productive
occupation the year prior to admission, and 47.4% at admission. The occupational rate
rose from 57.1% at 12 months to over 70% after 48 months. 65.6% maintained or
improved their occupational status. Most subjects held competitive employment, and
the employment rate was similar to that of the general population. Prior employment
and affective psychosis were associated with better outcome.
Implications: Indivdiuals experiencing a first episode of psychosis still maintain a
relatively strong attachments to the workforce (or to career development prospects).
Offering vocational support helps participants retain and improve their educational and
employment potential.
54.
Killackey, E., & Allott, K. (2013). Utilising Individual Placement and Support to
address unemployment and low education rates among individuals with psychotic
disorders. Australian and New Zealand Journal of Psychiatry, 47(6), 521-523. doi:
10.1177/0004867413476755
These authors review the research on the IPS model related to educational and
employment outclomes, which includes a section on ealry psychosis. Including
education and employment as an outcome led to 85% (Killackey et al., 2008) and 83%
(Nuechterlein et al., 2008) of participants in IPS conditions in these trials enjoying a
successful vocational outcome. The authors also note the promise of including cognitive
remediation as part of the support package.
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Implications: This review points to the promise of IPS supported emplyment and
education carried out in an early psychosis context.
55.
Bond, G. R., Drake, R. E., & Campbell, K. (2014). Effectiveness of individual
placement and support supported employment for young adults. Early Interv
Psychiatry, advance online publication. doi: 10.1111/eip.12175
To investigate the effects of IPS on young adults, the authors conducted a secondary
analysis on a pooled sample of 109 unemployed young adults (under age 30) from four
randomized controlled trials, assessing participants over 18 months on nine competitive
employment outcome measures. On all measures, the IPS group had significantly better
employment outcomes. Overall, over 80% of IPS participants obtained employment
during follow-up compared with just over 40% of control participants. IPS participants
averaged 25.0 weeks of employment, compared with 7.0 weeks for control participants.
Implications: the current analysis supports a small number of previous studies in
showing that IPS is highly effective in helping young adults with severe mental illness to
attain competitive employment.
56.
Drake, R. E., Xie, H., Bond, G. R., McHugo, G. J., & Caton, C. L. (2013). Early psychosis
and employment. Schizophr Res, 146(1-3), 111-117. doi: 10.1016/j.schres.2013.02.012
This study followed 351 participants with early psychoses for two years to examine their
patterns of competitive employment. The study compared workers and non-workers in
relation to service use, psychosocial outcomes, and disability and welfare payments. At
baseline, workers had better educational and employment histories, were more likely to
have substance-induced psychoses rather than primary psychoses, were less likely to
have drug dependence, had fewer negative symptoms, and had better psychosocial
adjustment. Over two years, baseline psychosocial differences persisted, and the
workers used fewer medications, mental health services, and disability or welfare
payments.
Implications: employment predicts less service use and fewer disability claims among
early psychosis participants. Thus, greater attention to supported employment early in
the course of illness may reduce insurance costs and disability payments.
57.
Rinaldi, M., Killackey, E., Smith, J., Shepherd, G., Singh, S. P., & Craig, T. (2010). First
episode psychosis and employment: A review. International Review of Psychiatry,
22(2), 148-162. doi:10.3109/09540261003661825.
Rinaldi et al. (2010) “First Episode Psychosis and Employment: A Review”, suggests that
people experiencing a first episode of psychosis, like others experiencing mental illness,
want to complete school and/or work, but face significant barriers doing so. Many are
falling out of school or work settings when they first contact services, and this trend
continues as they become engaged in care. Despite these barriers, recent studies of IPS in
first episode psychosis (including two randomized trials) showed employment and/or
education completion rates of 68%, versus 35% of controls.
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Implications: People with first episode psychosis may benefit equally, if not more so,
than others with serious mental illness from SE. These interventions may have to be
adapted to take the educational aspirations of participants into account, and as such
should blend SE with supported education.
58.
Eack, S. M., Greenwald, D. P., Hogarty, S. S., Cooley, S. J., DiBarry, A. L., Montrose,
D. M., & Keshavan, M. S. (2009). Cognitive enhancement therapy for early-course
schizophrenia: Effects of a two-year randomized controlled trial. Psychiatric Services,
60(11), 1468-1476. doi:10.1176/appi.ps.60.11.1468.
Eack et al. (2009) used Cognitive Enhancement Therapy for participants recently
diagnosed with schizophrenia, compared it to “enriched supportive therapy”, and
demonstrated superior cognition and employment outcomes (more likely to employed
and satisfied with their employment, greater earnings) than the comparison condition,
outcomes which were mediated by improvements in cognition (including social
cognition).
Implications: The study suggests that for participants with early psychosis, employment
outcomes can be successfully impacted with an innovative cognitive remediation
intervention alone. A significant but unanswered question is whether this model
compares favourably with IPS alone.
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SE and Homelessness
59.
Burt, M. R. (2012). Impact of housing and work supports on outcomes for chronically
homeless adults with mental illness: LA's HOPE. Psychiatric Services, 63(3), 209215.doi:10.1176/appi.ps.201100100.
Burt (2012) reports on the results of Los Angeles’ Project Hope, a demonstration project
offering supported employment and permanent supported housing to individuals with
mental illness who had previously been homeless. Fifty-is participants from three of Los
Angeles County’s 18 community mental health centers were studied over a period of 13
months. Demonstration project participants demonstrated significantly better housing
and employment outcomes than comparison group participants.
Implications: SE can be implemented successfully with people with very challenging
mental health histories, when combined with permanent supported housing.
Implementation of Critical Ingredients and Other Key Issues (Ongoing Job
Support/Longer-Term Job Retention; Benefits Counselling, Disclosure)
60.
Gewurtz, R. E., Cott, C., Rush, B., & Kirsh, B. (2012). The shift to rapid job placement
for people living with mental illness: An analysis of consequences. Psychiatric
Rehabilitation Journal, 35(6), 428-434. doi: 10.1037/h0094575
This article describes the consequences of the revised policy for employment supports
within the Ontario Disability Support Program, a disability benefit program
administered by the provincial government in Ontario, Canada. The revised policy
involves a change from a fee-for-service model to an outcome-based funding model,
which has encouraged a shift from preemployment to job placement services, with a
particular focus on rapid placement into available jobs. Using a qualitative case study
approach the analysis focused on exploring how the policy has been implemented in
practice, and its impact on employment services for individuals living with mental
illness. The findings show that although there is now an increased focus on employment
rather than preemployment supports, the financial imperative to place individuals into
jobs as quickly as possible has decreased attention to career development. Jobs are
reported to be concentrated at the entry-level with low pay and little security or benefits.
Implications: These findings raise questions of the impact of policy on implementation
of evidence-based supported employment.
61.
Menear, M., Reinharz, D., Corbiere, M., Houle, N., Lanctot, N., Goering, P., . . .
Lecomte, T. (2011). Organizational analysis of Canadian supported employment
programs for people with psychiatric disabilities. Soc Sci Med, 72(7), 1028-1035;
discussion 1036-1028. doi: 10.1016/j.socscimed.2011.02.005
While fidelity to principles and standards of the Individual Placement and Support
model is positively associated with vocational outcomes, studies have revealed
significant variations of implementation in Canada. This qualitative study aimed to
shed light on organizational and contextual factors influencing SE implementation in
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three Canadian provinces (British Columbia, Ontario and Quebec). Overall, 20 SE
programs provided by 15 different agencies were examined. Findings revealed that
agencies' exposure to different institutional pressures, their interactions and
relationships with other groups and organizations, as well as their values, beliefs and
ideologies played determining roles in shaping the evolution of SE services in each
province.
Implications: the organizational context within which supported employment is
imported can significantly shape implementation efforts.
62.
Swanson, S. J., Becker, D. R., & Bond, G. R. (2013). Job development guidelines in
supported employment. Psychiatr Rehabil J, 36(2), 122-123. doi: 10.1037/h0094988
Many employment specialists receive little training on how to work with employers and
resort to online job searches. Based on expdereince and published literaturre, this article
describes a simple framework for developing long-term relationships with employers,
which relies on network development strategies.
Implications: employment specialists benefit from a structured format to develop
relationships with employers, as well as good supervision in the field.
63.
Swanson, S. J., Courtney, C. T., Meyer, R. H., & Reeder, S. A. (2014). Strategies for
integrated employment and mental health services. Psychiatric Rehabilitation
Journal, 37(2), 86-89. doi: 10.1037/prj0000049
IPS supported employment for people with mental illness is most effective when mental
health and employment services are fully integrated within teams in a single agency.
Despite this evidence, there are times when separate mental health and employment
agencies must collaborate rather than integrate. This article examines how 3 state
implementation teams helped separate agencies to partner on IPS supported
employment, using qualitative interviews and direct observations to examine successful
collaborations in 3 states. The study found that leaders used 4 strategies to promote
successful collaborations, including: ensuring that employment specialists, and in some
cases, vocational rehabilitation counselors, attended mental health treatment team
meetings; providing office space for employment staff at the mental health agency;
involving supervisors from both agencies in the implementation; and using fidelity
reviews to assess the quality of collaboration.
Implications: practitioners from separate agencies can coordinate services effectively,
but successful coordination requires leadership at the policy and service delivery levels.
64.
Bond, G. R., Becker, D. R., Drake, R. E., Rapp, C. A., Meisler, N., Lehman, A. F., . . .
Blyler, C. R. (2001). Implementing supported employment as an evidence-based
practice. Psychiatric Services, 52(3), 313-322. doi:10.1176/appi.ps.52.3.313.
Bond, Becker et al. (2001) Implementing Supported Employment as an Evidence-Based
Practice: The objective of this article was to provide an accessible, plain language review
of the emerging findings, e.g. from the first Cochrane Review, of the Supported
Employment intervention. It defines SE, and distinguishes it from earlier approaches,
often situated at day hospitals or clubhouses, which emphasize lengthy pre-vocational
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periods using skills training, limited time job placements and sheltered workshops or
job units; by contrast SE program place high emphasis on job placement. The findings
show compared to traditional approaches, SE at least doubles the employment rate,
speeds up the time to first employment amongst those that do, and improves job tenure
for employed people; however, half of participants leave their first job within six
months. The critical ingredients of the model include: close coordination with clinical
services (e.g. case management), basing job search/placement on consumer preference
(rather than "readiness"), using employment specialists to find appropriate job settings
(job development), helping the participant undergo a rapid job search, and providing
indefinite follow-along supports (such as helping with workplace issues such as
accommodations and disclosure, being a job coach, participating in case management
meetings so that clinical barriers to continued employment can be addressed, and
commitment to competitive employment. This is defined as: 1) pays the minimum wage
or higher; 2) is located in a mainstream, socially integrated setting; 3) is not set aside for
persons with disabilities; and 4) is held independently, i.e., is not agency owned).
Caseload size, diverse employment settings, assertive outreach, and benefits counselling
have also been identified as critical ingredients, but are less studied. More research is
needed on long-term outcomes and on cost-effectiveness, but cost appears to be similar
to traditional programs (e.g. Day Programs) at about $2000 to 4000 per client, with some
suggestion that this cost may be offset by lower clinical costs.
Implications: Compared to traditional programs, SE interventions following certain
principles (or critical ingredients) double the employment rates for people with serious
mental illness who want to work.
65.
Tremblay, T., Smith, J., Xie, H., & Drake, R. E. (2006). Effect of benefits counseling
services on employment outcomes for people with psychiatric disabilities. Psychiatric
Services, 57(6), 816-821. doi: 10.1176/appi.ps.57.6.816.
Tremblay, Smith, Xie, and Drake (2006) showed that clients of vocational rehabilitation
programs receiving specialized benefits counselling (regarding work incentives,
managing benefits during transition to employment and information to supporting
professionals) made $100 more per month than a comparison group of vocational
rehabilitation participants not receiving the counselling.
Implications: This study provides some research support to the common sense notion
that benefits counselling helps employment outcomes, and as such should be considered
a critical ingredient to SE.
66.
Bond, G. R., & Kukla, M. (2011). Impact of follow-along support on job tenure in the
individual placement and support model. The Journal of Nervous and Mental Disease,
199(3), 150-155. doi:10.1097/NMD.0b013e31820c752f.
Bond and Kukla (2011) looked at the role of providing ongoing vocational support for
clients who obtain employment, a putatively critical, but unverified, aspect of the IPS
model, and showed that frequency of ongoing contact was positively and related to job
tenure (months of work during the two-year follow-up period).
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Implications: The study supports the typical practice of ongoing vocational support as
an important contributor to vocational success, suggesting that IPS program provide
weekly support in the initial two months following job acquisition, then monthly checkins thereafter. The authors pose the question of the characteristics of effective job
specialists, and the need to gather further information on this issue.
Alternative Program Delivery Contexts for SE (Clubhouse, PACT, IPS
Within Consumer-Run Organization)
67.
Macias, C., Rodican, C. F., Hargreaves, W. A., Jones, D. R., Barreira, P. J., & Wang, Q.
(2006). Supported employment outcomes of a randomized controlled trial of ACT and
clubhouse models. Psychiatric services, 57(10), 1406-1415.
doi:10.1176/appi.ps.57.10.1406.
Macias et al. (2006) compared benchmark SE outcomes with employment-related
outcomes for SE delivered within the context of a certified clubhouse, and of an
integrated PACT model, and found comparable employment rates for both ACT and
clubhouse models (64% and 47% respectively). Over 24 months, ACT participants had
superior service engagement, and better retention rates than Clubhouse participants
(98% vs. 74%; and 79% vs. 58%, respectively), however clubhouse participants had better
employment performance over the same period, in that they worked significantly more
hours (494 vs. 234), over a significantly longer period (199 days vs. 98 days), an effect the
authors attribute in part to the higher earnings earned by clubhouse participants ($3,456
vs. $1,252 total earnings). The difference in employment rates was non-significant.
Implications: Certified clubhouses can achieve similar employment outcomes to those
of published “model” SE programs, as well as deliver other rehabilitative supports. ACT
programs that integrate employment specialists can also achieve these outcomes, as well
as integrated clinical care. This suggests that both certified clubhouses and integrated
ACT teams are viable models for SE, a conclusion that is contrary to those found by
systematic reviews of SE, which generally favour the IPS model. The study raises the
question of why these particular programs have achieved relatively higher employment
outcomes, and whether it is possible that these program contexts can also deliver the
same essential ingredients provided by IPS.
68.
Schonebaum, A. D., Boyd, J. K., & Dudek, K. J. (2006). A comparison of competitive
employment outcomes for the clubhouse and PACT models. Psychiatric Services,
57(10), 1416-1420. doi: 10.1176/appi.ps.57.10.1416.
Schonebaum, Boyd, and Dudek (2006) compared competitive employment rates for ACT
and clubhouse models. After 30 months, participants in both groups had similar
employment placement rates, and hours worked per week. Clubhouse participants
earned more, and remained employed in significantly more hours per job worked. Both
PACT and clubhouse participants had high employment placement rates (74% vs. 60%)
respectively.
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Implications: This study suggests that ACT and clubhouses are promising models for
delivering SE.
69.
Barreira, P. J., Tepper, M. C., Gold, P. B., Holley, D., & Macias, C. (2011). Adapting
evidence-Based interventions to fit usual practice: Staff roles and consumer choice in
psychiatric rehabilitation. Psychiatric Quarterly, 81(2), 139-155. doi:10.1007/s11126-0109124-4.
Barreira, Tepper, Gold, Holley, and Macias (2011) point out that multi-service settings
(such as clubhouses or drop-in centres) providing rehabilitative support across various
domains (supported socialization, housing, education, health promotion, cognitive and
social skill training) are increasingly adopting evidence-based practices (EBP) but are
challenged by fidelity standards of SE and other EBP’s requiring that programs hire
employment specialists. This study demonstrated that a generalist approach could
achieve similar outcomes to published IPS results in terms of increases in mainstream
employment, and showed that these results were associated with number of days clients
participate in SE supports, and with number of independent providers. This suggests
that the generalist model can approximate the effectiveness of traditional IPS, and that in
real world settings this may be a viable option for implementing high quality SE.
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References – Supported Employment
Abdel-Baki, A., Létourneau, G., Morin, C., & Ng, A. (2013). Resumption of work or studies
after first-episode psychosis: the impact of vocational case management. Early
Intervention in Psychiatry, 7(4), 391-398. doi: 10.1111/eip.12021
Barreira, P. J., Tepper, M. C., Gold, P. B., Holley, D., & Macias, C. (2011). Adapting evidenceBased interventions to fit usual practice: Staff roles and consumer choice in psychiatric
rehabilitation. Psychiatric Quarterly, 81(2), 139-155. doi:10.1007/s11126-010-9124-4
Bejerholm, U., Areberg, C., Hofgren, C., Sandlund, M., & Rinaldi, M. (2015). Individual
Placement and Support in Sweden—A randomized controlled trial. Nordic Journal of
Psychiatry, 69(1), 57-66. doi: doi:10.3109/08039488.2014.929739
Bell, M. D., Choi, K.-H., Dyer, C., & Wexler, B. E. (2014). Benefits of cognitive remediation
and supported employment for schizophrenia patients with poor community
functioning. Psychiatric Services, 65(4), 469-475.
Bond, G. R., Drake, R. E., & Campbell, K. (2014). Effectiveness of individual placement and
support supported employment for young adults. Early Interv Psychiatry, advance
online publication. doi: 10.1111/eip.12175
Bond, G. R., Becker, D. R., & Drake, R. E. (2011). Measurement of Fidelity of Implementation
of Evidence-Based Practices: Case Example of the IPS Fidelity Scale. Clinical
Psychology: Science and Practice, 18(2), 126-141. doi: 10.1111/j.1468-2850.2011.01244.x
Bond, G. R., Becker, D. R., Drake, R. E., Rapp, C. A., Meisler, N., Lehman, A. F., . . . Blyler, C. R.
(2001). Implementing supported employment as an evidence-based practice. Psychiatric
Services, 52(3), 313-322. doi:10.1176/appi.ps.52.3.313
Bond, G. R., Drake, R. E., & Becker, D. R. (2012). Generalizability of the Individual
Placement and Support (IPS) model of supported employment outside the US. World
Psychiatry, 11(1), 32-39.
Bond, G. R., Resnick, S. G., Drake, R. E., Xie, H., McHugo, G. J., & Bebout, R. R. (2001). Does
competitive employment improve nonvocational outcomes for people with severe
mental illness? Journal of Consulting and Clinical Psychology, 69(3), 489-501.
doi:10.1037/0022-006X.69.3.489
Bond, G. R. (2008). An update on randomized controlled trials of evidence-based supported
employment. Psychiatric Rehabilitation Journal, 31(4), 280-290.
doi:10.2975/31.4.2008.280.290
Bond, G. R., & Kukla, M. (2011). Impact of follow-along support on job tenure in the individual
placement and support model. The Journal of Nervous and Mental Disease, 199(3), 150-155.
doi:10.1097/NMD.0b013e31820c752f
Burns, T., & Catty, J. (2008). IPS in Europe: The EQOLISE trial. Psychiatric Rehabilitation Journal,
31(4), 313-317. doi: 10.2975/31.4.2008.313.317
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Burt, M. R. (2012). Impact of housing and work supports on outcomes for chronically homeless
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Hoffmann, H., Jäckel, D., Glauser, S., Mueser, K., & Kupper, Z. (2014). Long-Term
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Kern, R. S., Zarate, R., Glynn, S. M., Turner, L. R., Smith, K. M., Mitchell, S. S., . . . Liberman,
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Mueser, K. T., Clark, R. E., Haines, M., Drake, R. E., McHugo, G. J., Bond, G. R., . . . Swain, K.
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Wellness Management & Recovery Interventions
IMR and related interventions: Reviews and Background Papers
70.
McGuire, A. B., Kukla, M., Green, A., Gilbride, D., Mueser, K. T., & Salyers, M. P.
(2014). Illness management and recovery: a review of the literature. Psychiatr Serv,
65(2), 171-179. doi: 10.1176/appi.ps.201200274
Illness Management and Recovery (IMR) is a standardized psychosocial intervention
that is designed to help people with severe mental illness manage their illness and
achieve personal recovery goals. This literature review summarizes the research on
consumer-level effects of IMR and articles describing its implementation. Three RCTs,
three quasi-controlled trials, and three pre-post trials have been conducted. The RCTs
found that consumers receiving IMR reported significantly more improved scores on the
IMR Scale (IMRS) than consumers who received treatment as usual. IMRS ratings by
clinicians and ratings of psychiatric symptoms by independent observers were also
more improved for the IMR consumers. Implementation studies (N=16) identified
several important barriers to and facilitators of IMR, including supervision and agency
support. Implementation outcomes, such as participation rates and fidelity, varied
widely.
Implications: IMR shows promise for improving some consumer-level outcomes.
Future research is needed to compare outcomes of IMR consumers and active control
groups and to provide a more detailed understanding of how other services may affect
outcomes of IMR.
71.
Kelly, E. L., Fenwick, K. M., Barr, N., Cohen, H., & Brekke, J. S. (2014). A Systematic
Review of Self-Management Health Care Models for Individuals With Serious
Mental Illnesses. Psychiatr Serv. doi: 10.1176/appi.ps.201300502
The general medical health of individuals with serious mental illnesses is compromised
relative to those without serious mental illnesses. However, self-management of health
care, a strategy considered an integral aspect of typical care, has been infrequently
offered. To understand whether these models are supported, the authors reviewed the
evidence for self-management models. Across the 14 studies identified in this review,
promising evidence was found that individuals with serious mental health issues can
collaborate with health professionals or be trained to self-manage their health and health
care. The evidence supports the use of peers or professional staff to implement health
care interventions. The substantial heterogeneity in study design, types of training, and
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examined outcomes limits the types of conclusions that can be drawn about the
comparative effectiveness of existing studies.
Implications: This review found preliminary support that self-management
interventions targeting the general medical health of those with serious mental illnesses
are efficacious. Future work is needed to determine what elements of training or skills
lead to the most signifcant changes.
72.
Sterling, E. W., von Esenwein, S. A., Tucker, S., Fricks, L., & Druss, B. G. (2010).
Integrating wellness, recovery, and self-management for mental health consumers.
Community Mental Health Journal, 46(2), 130-138. doi: 10.1007/s10597-009-9276-6.
Sterling, von Esenwein, Tucker, Fricks, and Druss (2010) in “Integrating Wellness,
Recovery & Self-Management” suggest that these three interrelated concepts are
complementary and share an underlying similarity of empowering consumers to direct
their mental health care. Self-management interventions have helped individuals with
various chronic illnesses develop the confidence and skills to address their conditions on
a day-to-day basis. This approach also holds unrealized potential for people with serious
mental illness and concurrent disorders, especially when situated within a recovery
and/or wellness framework. The concept of wellness highlights broader healthy lifestyle
and well-being concerns sometimes included but not always emphasized by the
recovery philosophy.
Implications: The authors argue that rather than competing for resources, interventions
that integrate wellness, recovery and self-management should be implemented as a
coherent package. They discuss interventions which do so, including the Wellness
Recovery Action Plan (WRAP) intervention, BRIDGES, and the HARP program,
described below.
73.
Mueser, K. T., Corrigan, P. W., Hilton, D. W., Tanzman, B., Schaub, A., Gingerich, S., .
. . Herz, M. I. (2002). Illness management and recovery: A review of the research.
Psychiatric Services, 53(10), 1272-1284. doi: 10.1176/appi.ps.53.10.1272.
A review (Mueser, Corrigan et al., 2002) begins by defining recovery, which entails
discovering or recovering strengths, moving towards life goals, and reclaiming an
identity beyond illness. The paper then reviews professionally-led illness management
interventions, categorizing these into: psychoeducation, which helps individuals learn
more about their condition by providing basic information, behavioural tailoring, which
helps individuals take medications as prescribed by integrating these into their daily
routine, relapse prevention which helps individuals reduce symptom relapses and
rehospitalizations by identifying relapse triggers and warning signs and developing
preventive plans, and coping skills training, using cognitive behavioural therapeutic
(CBT) techniques, which helps individuals deal with symptoms and/or stress, and
reduce the severity and distress of symptoms by increasing the use of currently effective
strategies or learning new ones.
Implications: This paper identifies a number of critical ingredients that when grouped
together can be considered an evidence based practice. Consistent with the first
Cochrane Review (Pekalla & Merinder, 2002), this review emphasizes that
Wellness Management & Recovery Interventions
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psychoeducation alone is usually not sufficient to impact compliance or relapse. The
paper is significant in that it emphasizes that psychoeducation provides the basis for a
more comprehensive approach to increasing compliance and reducing service use. All of
the elements of the more comprehensive approach (psychoeducation, cognitive and
behavioural approaches to treatment engagement, relapse prevention and CBT-based
coping skills training) were subsequently developed into a standardized intervention
(Illness Management & Recovery, or IMR) that is being implemented and trialed in the
United States and other countries (see below). The authors point out that at this point
there is not enough evidence to suggest that IMR-related interventions are sufficient to
impact on broader quality of life, or impact on broader recovery/wellness-related
outcomes. The authors call for more research on this issue as well as on consumer-led
wellness management approaches, such as the Wellness Recovery Action Plan or WRAP
program (see below).
74.
Mueser, K. T., Meyer, P. S., Penn, D. L., Clancy, R., Clancy, D. M., & Salyers, M. P.
(2006). The illness management and recovery program: Rationale, development, and
preliminary findings. Schizophrenia Bulletin, 32(Suppl.1), S32-S43. doi:
10.1093/schbul/sbl022.
A paper (Mueser, Meyer et al., 2006) entitled “the IMR program: Rationale and
Preliminary Findings”, describes the IMR intervention and provides preliminary
research demonstrating its acceptability to participants, the feasibility of implementing it
in different contexts (US and Australia), and provides data regarding positive outcomes.
The program incorporates the four components identified in Mueser, Corrigan et al.
(2002), and adds a fifth component, building social support networks. It is offered as a
series of modules (e.g., recovery strategies, practical facts about mental illnesses, stress
vulnerability model, building medication effectively, drug and alcohol abuse, etc.)
offered on a one to one or group basis over a period of nine or ten months, generally in
one hour sessions provided once a week. Consistent with one of the theoretical
frameworks of the intervention, Proschaka’s et al. transtheoretical model of change, in
each module participants learn and discuss the new material in the context of their life
goals. The authors present preliminary evidence suggesting strong improvements in
self-reported effectiveness in coping with symptoms, and clinician-reported global
functioning.
Implications: This study showed that a standardized intervention, IMR, which
incorporates the critical ingredients of illness management, can be successfully
implemented and could achieve positive results and set the stage for future research (see
below: Illness Management & Recovery: intervention trials).
Illness Management & Recovery: Evidence on Intervention Types
(Motivational Approaches, Psychoeducation, CBT, Other Psychosocial
Interventions, Family Psychoeducation)
75.
Lyman, D. R., Braude, L., George, P., Dougherty, R. H., Daniels, A. S., Ghose, S. S., &
Delphin-Rittmon, M. E. (2014). Consumer and family psychoeducation: assessing the
evidence. Psychiatr Serv, 65(4), 416-428. doi: 10.1176/appi.ps.201300266
Wellness Management & Recovery Interventions
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Psychoeducation, an aspect of the IMR model (described below – see Mueser et al., 2002)
provides people with serious mental illness or co-occurring substance use disorders with
information to support recovery. Some models also provide this service to family
members. This review examined the evidence base for psychoeducation models in
group and individual formats. Authors reviewed meta-analyses, research reviews, and
individual studies from 1995 through 2012 finding more than 30 randomized controlled
trials (RCTs) of consumer psychoeducation and more than 100 RCTs of family
psychoeducation, which provide a high level of evidence for the effectiveness of each
model. Reviews of consumer psychoeducation found that experimental groups had
reduced nonadherence (primarily with medication regimens), fewer relapses, and
reduced hospitalization rates compared with control groups. Some studies found
significant improvements in social and global functioning, consumer satisfaction, and
quality of life. Multifamily psychoeducation groups (the focus of numerous studies)
were associated with significantly improved problem-solving ability and a reduced
burden on families, compared with control groups, among other strong outcome effects.
Implications: Psychoeducation should be offered to consumers and families.
76.
Lincoln, T. M., Wilhelm, K., & Nestoriuc, Y. (2007). Effectiveness of psychoeducation
for relapse, symptoms, knowledge, adherence and functioning in psychotic disorders:
A meta-analysis. Schizophrenia Research, 96(1), 232-245. doi:
10.1016/j.schres.2007.07.022.
A meta-analysis on psychoeducational interventions (Lincoln, Wilhelm, & Nestoriuc,
2007) examined interventions that fit the Mueser et al. (2002) definition of illnessmanagement in that they provided information, as well as coping skills and strategies.
This analysis also examined whether interventions that included families would be more
effective than those directed solely at consumers, and found that interventions that
included families were more effective at reducing symptoms by the end of treatment,
and reducing relapse at the 7-12 month follow-up period.
Implications: Practitioners should explore the benefits with consumers of involving
significant others in illness or wellness management interventions.
77.
McIntosh, A., Conlon, L., Lawrie, S., & Stanfield, A. C. (2009). Compliance therapy for
schizophrenia. Cochrane Database of Systematic Reviews. doi:
10.1002/14651858.CD003442.pub2.
This review describes the intervention, which is based on motivational interviewing
principles, and helps clients review their history of illness, as well as the potential
benefits and drawbacks of taking medication for schizophrenia. The review only
included one study and found no significant impact on compliance or attitudes towards
medication, but a trend towards reduction in time spent in the hospital over a two-year
period.
Implications: The authors maintain that the approach holds promise and should be
studied further.
Wellness Management & Recovery Interventions
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45
78.
Haynes, B. R., Ackloo, E., Sahota, N., McDonald, H. P., & Yao, X. (2008). Interventions
for enhancing medication adherence. Cochrane Database of Systematic Reviews. doi:
10.1002/14651858.CD000011.pub3.
A Cochrane Review of medication adherence interventions (Haynes, Ackloo, Sahota,
McDonald, & Yao, 2008) looked at interventions for various health conditions, which
included serious mental illness, but not addictions.
Implications: The review found that in order to be effective the interventions that
enhanced adherence were generally complex, and included multiple facets, including
providing information, making care more convenient, giving telephone reminders, and
other forms of individual follow-up and supervision. The impacts on adherence were
generally modest and generally did not extend to other clinical outcomes.
79.
Xia, J., Merinder, L. B., Belgamwar, M. R. (2011). Psychoeducation for schizophrenia.
Cochrane Database of Systematic Reviews. doi: 10.1002/14651858.CD002831.pub2.
A Cochrane Review of psychoeducational interventions, (Xia, Merinder, & Belgamwar,
2011) examined interventions that were consistent with Mueser et al. (2002;2006)
definition of illness-management in that they provided information but also sought to
influence attitudinal and behavioural change. The findings were consistent with the
earlier review, showing that these interventions can improve compliance, reduce relapse
and rehospitalisation. There was also some evidence that they can improve quality of
life and social functioning.
Implications: This review provides no helpful information that could supplement the
Mueser et al.’s (2002;2006) advice as to what the critical components of these
interventions should be, nor as to how long they should be carried out for, but it does
reinforce the conclusion that illness management interventions should be implemented
more broadly.
80.
Wykes, T., Steel, C., Everitt, B., & Tarrier, N. (2008). Cognitive behavior therapy for
schizophrenia: Effect sizes, clinical models, and methodological rigor. Schizophrenia
Bulletin, 34(3), 523-537. doi: 10.1093/schbul/sbm114.
A review of CBT for psychosis by Wykes, Steel, Everitt, & Tarrier, (2008) looked not only
at the effectiveness of the intervention for addressing positive symptoms, but also other
outcomes such as negative symptoms, functioning, mood and social anxiety. The results
showed positive outcomes on all of these outcomes.
Implications: CBT for psychosis can impact on a wide range of outcomes, over and
above the area considered its specific benefit, i.e. helping people deal with symptoms
that don’t respond to medication.
81.
Jones, C., Hacker, D., Cormac, I., Meaden, A., & Irving, C. B., (2012). Cognitive
behaviour therapy versus other psychosocial treatments for schizophrenia. Cochrane
Database of Systematic Reviews. doi: 10.1002/14651858.CD008712.pub2.
Wellness Management & Recovery Interventions
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A Cochrane Review comparing CBT for psychosis with less sophisticated psychosocial
interventions for people with schizophrenia (Jones, Hacker, Cormac, Meaden, & Irving,
2012) found no clear advantage of CBT, in terms of reducing relapse/rehospitalisation,
or addressing positive and negative symptoms.
Implications: Less sophisticated psychosocial interventions consistent with the IMR
approach may achieve similar results to CBT.
82.
Pharoah, F., Mari, J., Rathbone, J., & Wong, W. (2010). Family intervention for
schizophrenia. Cochrane Database of Systematic Reviews. doi:
10.1002/14651858.CD000088.pub3.
A Cochrane Review (Pharoah, Mari, Rathbone, & Wong, 2010) on family
psychoeducational interventions (many of which provide basic illness-related
information, use structured problem solving approaches, provide communication skill
training, and include both consumers and families, using individual and multi-family
formats) suggests that family interventions can reduce “expressed emotion” (i.e.
improve consumer/family interaction styles), and may reduce relapse, rehospitalisation,
and treatment compliance.
Implications: Where relevant, psychoeducational and broader IMR/WMR interventions
should consider including family members and significant others.
“Illness Management & Recovery” Intervention trials
83.
Salyers, M. P., McGuire, A. B., Kukla, M., Fukui, A., Lysaker, P., & Mueser, K. T.
(2014). A Randomized Controlled Trial of Illness Management and Recovery With an
Active Control Group. Psychiatric Services, 65(8), 1005-1011. doi:
doi:10.1176/appi.ps.201300354
The purpose of the study was to test IMR against an active control group or a problemsolving intervention, using an RCT design. Groups met weekly for nine months. No
significant differences were found between IMR and problem-solving groups on
assessments of symptoms, functioning, illness self-management, medication adherence,
subjective recovery experiences, and service utilization. Participants in both groups
improved significantly over time in symptom severity, illness management, and quality
of life and had fewer emergency department visits. Participation rates in both
interventions were low. Only 28% of people assigned to IMR and 17% of those assigned
to the problem-solving group participated in more than half the scheduled groups, and
23% and 34%, respectively, attended no sessions.
Implications: This is the first randomized controlled trial of IMR to report negative
findings. Given the inclusion of an active control group and the low participation rates,
further research is needed to understand factors affecting IMR effectiveness in relation
to other interventions including possibly similar active ingredients. Increased attention
may need to be paid to facilitate more active participation in IMR, such as individual
follow-up with consumers and the integration of IMR with ongoing treatment.
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84.
Garber-Epstein, P., Zisman-Ilani, Y., Levine, S., & Roe, D. (2013). Comparative impact
of professional mental health background on ratings of consumer outcome and
fidelity in an illness management and recovery program. Psychiatric Rehabilitation
Journal, 36(4), 236-242. doi: 10.1037/prj0000026
Objective: This study examines the impact of practitioners who were mental health
professionals, peer providers, or paraprofessionals on fidelity and consumer outcome in
IMR. Regardless of practitioner background, consumers who received the IMR
intervention demonstrated significant improvement compared to the control group,
with no statistically significant difference on consumer outcome regardless of whether
the practitioner was a professional, paraprofessional, or a peer provider. All three IMR
groups had good fidelity scores.
Implications: The results demonstrate that IMR can be implemented with good fidelity
and generate positive outcomes when delivered by practitioners who receive sufficient
training and supervision regardless of their professional background.
85.
Färdig, R., Lewander, T., Melin, L., Folke, F., & Fredriksson, A. (2011). A randomized
controlled trial of the illness management and recovery program for persons with
schizophrenia. Psychiatric Services, 62(6), 606-612. doi:10.1176/appi.ps.62.6.606.
Färdig, Lewander, Melin, Folke, and Fredriksson (2011) implemented the IMR approach
in Sweden, using a group-based approach including app. five participants in each of six
study centres. This RCT showed that compared to controls, participants showed better
illness management ability post-treatment and at 21 month follow-up, and were also less
symptomatic and demonstrated better coping ability, for instance better using the
support of others, and adopting proactive strategies for problem-solving illness-related
issues.
Implications: Even with participants who already receive extensive community support,
the IMR intervention can improve self-management ability. The study also shows the
generalizability of results beyond the U.S.
86.
Hasson-Ohayon, I., Roe, D., & Kravetz, S. (2007). A randomized controlled trial of the
effectiveness of the illness management and recovery program. Psychiatric Services,
58(11), 1461-1466. doi: 10.1176/appi.ps.58.11.1461.
Hasson-Ohayon, Roe, and Kravetz (2007) implemented a group-based form of the IMR
intervention described above in eight centres in Israel. Their RCT found that compared
to controls, participants in the IMR intervention showed significant improvement in
knowledge about the illness and made greater progress towards personal goals.
Clinicians also rated the intervention group as showing greater overall improvement.
Both groups improved their ability to cope with the illness, though the intervention sites
with greater fidelity to the IMR model did show an increase in coping compared to
treatment as usual. No change in social support was found in either group.
Implications: This study, the first RCT of the IMR intervention, suggests that a
standardized, well-implemented but flexible approach to IMR can significantly
contribute to coping and attainment of broader recovery goals.
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Impact of IMR in Inpatient Settings
87.
Bartholomew, T., & Zechner, M. (2014). The Relationship of Illness Management and
Recovery to State Hospital Readmission. The Journal of Nervous and Mental Disease,
202(9), 647-650 610.1097/NMD.0000000000000177.
This study examined the association between number of hours attended of the Illness
Management and Recovery (IMR) program and psychiatric readmission rates after
discharge from a state psychiatric hospital, using a large sample drawn from archival
data. After controlling for the client characteristics on a number of key variables it was
found that, for each hour of IMR, there was an associated 1.1% reduction in the risk for
returning to the hospital.
Implications: This suggests that participation in IMR while in inpatient settings may
assist individuals in reducing their risk for returning to the hospital.
88.
Lin, E. C.-L., Chan, C. H., Shao, W.-C., Lin, M.-F., Shiau, S., Mueser, K. T., . . . Wang,
H.-S. (2013). A randomized controlled trial of an adapted Illness Management and
Recovery program for people with schizophrenia awaiting discharge from a
psychiatric hospital. Psychiatric Rehabilitation Journal, 36(4), 243-249. doi:
10.1037/prj0000013
Most research on theI MR program has focused on individuals with stable symptoms
living in the community. The authors of this sutdy evaluated the feasibility and effects
of an IMR program adapted for individuals with schizophrenia who were awaiting
discharge into the community, using an RCT in two Taiwanese hospitals that included
approximately 100 people randomized to either IMR or treatment as usual. The study
found that participants in the adapted IMR group showed significantly greater
improvements at posttreatment and 1-month follow-up in illness-management
knowledge, attitudes toward medication, insight, and negative symptoms than
individuals in the TAU group.
Implications: This is the first controlled evaluation of a version of the IMR program in
an East Asian culture, and the first to evaluate it in an acute care inpatient setting. The
findings support the feasibility and potential benefits of implementing an adapted IMR
program, focused on the prevention of relapses and rehospitalizations during the
discharge plannig period.
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89.
Roe, D., Hasson-Ohayon, I., Salyers, M. P., & Kravetz, S. (2009). A one year follow-up
of illness management and recovery: Participants' accounts of its impact and
uniqueness. Psychiatric Rehabilitation Journal, 32(4), 285-291. doi:
10.2975/32.4.2009.285.291.
A 1-year follow-up of the IMR trial (Roe, Hasson-Ohayon, Salyers, & Kravetz, 2009) was
a qualitative study conducted with approximately 30 participants from within eight of
the IMR implementation centres described by the Hasson-Ohayon et al (2007), paper. It
looked in an open-ended fashion for outcomes experienced, as well as sought to
understand the elements of the intervention process that may have contributed to these.
It showed that one year after the program ended, participants continued to experience
the benefits of the program, the majority of whom continued to experience a high
positive impact. Unanticipated outcomes included impact on cognitive ability (e.g.
concentration), as well as improvements in social support and ability. The format of the
program, including the workbook, and the interactive aspect (the Israeli study was
implemented in a group-based format) was perceived as contributing to the
intervention’s helpfulness. Compared to previous interventions, the IMR intervention
was perceived as considerably more hopeful in nature.
Implications: The group-based form of IMR in particular may contribute to social
support and may accentuate the intervention’s ability to convey useful information and
skills, and to convey hope for recovery.
90.
Salyers, M. P., Rollins, A. L., Clendenning, D., McGuire, A. B., & Kim, E. (2011).
Impact of illness management and recovery programs on hospital and emergency
room use by medicaid enrollees. Psychiatric Services, 62(5), 509-515. doi:
10.1176/appi.ps.62.5.509.
A study looking at IMR integrated with ACT (Salyers, Rollins et al., 2011) examined
impact on hospital service use, examined hospitalization rates within five Assertive
Community Treatment teams that implemented the IMR approach, and showed that
IMR program attendees and graduates were more likely to have no hospitalization, had
fewer hospitalization days and fewer emergency room visits than participants who
received ACT only. The approach was implemented on an individual basis, rather than
in a group-based format. This is the first study to demonstrate the impact of IMR on
service usage.
Implications: This was an observational study, but the ability of IMR to improve the
already high impact of ACT on service use is promising. Participants tended to have
more education (which may suggest difficulties with the accessibility of the program,
which contains written material that may be experienced as intensive). As participants
were more likely to live in supportive housing than independently, and be white and
male; also, the study was conducted in one state (Indiana). All of these factors raise
questions about the generalizability of the results.
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91.
Salyers, M. P., McGuire, A. B, Rollins, A. L., Bond, G. R., Mueser, K. T., & Macy, V. R.
(2010). Integrating assertive community treatment and illness management and
recovery for consumers with severe mental illness. Community Mental Health Journal,
46(4), 319-329. doi: 10.1007/s10597-009-9284-6.
Another paper by the same research group (Salyers, McGuire et al., 2010) provides
additional information on the initiative to integrate IMR specialists within ACT teams
using peer specialists. As found in Salyers, Rollins et al.’s (2011), those individuals
actually exposed to the intervention experienced lower hospital service usage. However,
the authors point to certain implementation challenges. For instance, ACT team
members may feel pressure to do crisis oriented work which can take away from IMR
work. The individually provided approach limits the “penetration rate” of IMR, which
limited the intervention to only approximately 25% of consumers on ACT teams during
the study period.
Implications: ACT teams can benefit from implementing IMR, but need to develop
strategies for integrating this work into day to day practice in ways that can realize its
benefits.
92.
Lecomte, T., Leclerc, C., Corbière, M., Wykes, T., Wallace, C. J., & Spidel, A. (2008).
Group cognitive behavior therapy or social skills training for individuals with a
recent onset of psychosis? Results of a randomized controlled trial. The Journal of
Nervous and Mental Disease, 196(12), 866-875. doi: 10.1097/NMD.0b013e31818ee231.
Lecomte et al. (2008) report on the results of this Canadian study, an RCT comparing
group-based CBT, group-based social skills training (based on the Liberman model), and
a waitlist control group. The interventions were carried out within early psychosis
clinics in BC and Quebec by non-specialist staff, and outcome measures for the 129
participants were taken at 3 and 9 months. Compared to the waitlist control group, the
CBT group showed improvements on overall symptoms, self-esteem, and active-coping
strategies. Both intervention groups improved on negative and positive symptoms.
Implications: This group-based intervention holds promise for participants with early
psychosis, and can be feasibly implemented in Canadian service delivery contexts.
Wellness Recovery Action Plan (WRAP) and Other Peer-Led or PeerProfessional Led Wellness Management Intervention Studies
93.
Cook, J. A., Jonikas, J. A., Hamilton, M. M., Goldrick, V., Steigman, P. J., Grey, D. D., .
. . Copeland, M. E. (2013). Impact of Wellness Recovery Action Planning on service
utilization and need in a randomized controlled trial. Psychiatric Rehabilitation
Journal, 36(4), 250-257. doi: 10.1037/prj0000028
This study examined the impact of WRAP on the use of and need for mental health
services over time compared with a control group offered nutrition and wellness
education, using an RCT design including over 140 individuals. The WRAP intervention
was delivered by peers in recovery from serious mental illness who were certified
WRAP educators over nine weekly sessions lasting 2.5 hrs. The nutrition education
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curriculum was taught by trained non-peer educators using the same schedule. T'he
analysis indicated that, compared with controls, WRAP participants reported
significantly greater reduction over time in service utilization (total, individual, and
group), and service need (total and group services). Participants in both interventions
improved significantly over time in symptoms and recovery outcomes.
Implications: This confirms the importance of WRAP in an era of dwindling behavioral
health service availability and access.
94.
Cook, J. A., Copeland, M. E., Jonikas, J. A., Hamilton, M. M., Razzano, L. A., Grey, D.
D., . . . Boyd, S. (2012). Results of a randomized controlled trial of mental illness selfmanagement using wellness recovery action planning. Schizophrenia Bulletin, 38(4),
881-891.
The purpose of this study was to determine the efficacy of a peer-led illness selfmanagement intervention called Wellness Recovery Action Planning (WRAP) by
comparing it with usual care in over 500 adults in 6 Ohio communities randomly
assigned to the 8-week intervention or a wait-list control condition. WRAP participants
reported significantly greater reduction over time in symptom severity and positive
symptoms, and enhanced quality of life.
Implications: This confirms the importance of peer-led wellness management
interventions, such as WRAP, as part of evidence-based recovery-oriented services
offered to people with serious mental illness.
95.
Cook, J. A., Copeland, M. E., Hamilton, M. M., Jonikas, J. A., Razzano, L. A., Floyd, C.
B., . . . Grey, D. D. (2009). Initial outcomes of a mental illness self-management
program based on wellness recovery action planning. Psychiatric Services, 60(2), 246249. doi: 10.1176/appi.ps.60.2.246.
A paper on WRAP initial outcomes (Cook, Copeland, Hamilton et al., 2009) describes
this intervention and presents initial findings. WRAP is delivered over a course of eight
weeks, co-facilitated by two peer facilitators offering a 2.5 hour session, once per week.
Facilitators have completed the program and attended a five-day process to certify them
as “recovery educators”. The program is intended for individuals with a variety of
conditions who may or may not identify their issues with the medical model or
participate in formal mental health services. Unlike IMR it avoids use of diagnostic
labels, but similar to IMR helps participants learn about triggers and warning signs of
relapse. WRAP participants develop a “wellness and recovery” action plan by
developing coping skills for avoiding relapse and staying well. Peer modelling and
drawing on the personal experiences of facilitators and participants is integral to the
intervention. This initial study, a pre-post evaluation across five study sites in Ohio,
showed improvements in a number of self-management related outcomes, including
symptoms, hope, and physical health. No changes were found in social support.
Implications: This first published study of WRAP shows that the peer-led model is
consistent with illness management and recovery critical ingredients, that it appears
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feasible to implement, and holds potential in improving illness management and
recovery-related outcomes. WRAP may be a preferable alternative for people who do
not adopt the illness model of mental health.
96.
Cook, J. A., Copeland, M. E., Corey, L., Buffington, E., Jonikas, J. A., Curtis, L. C., . . .
Nichols, W. H. (2010). Developing the evidence base for peer-led services: Changes
among participants following Wellness Recovery Action Planning (WRAP) education
in two statewide initiatives. Psychiatric Rehabilitation Journal, 34(2), 113-120. doi:
10.2975/34.2.2010.113.120.
Cook, Copeland, Corey et al. (2010) present results from a pre-post evaluation in two
states (Vermont and Minnesota) where the WRAP program was implemented in
multiple regions. The results showed significant changes in participants’ wellness
management knowledge, abilities and attitudes, including hopefulness about recovery,
awareness of triggers and warning signs, and knowledge of strategies for staying well.
Implications: This study provides further evidence of the promise of the WRAP model
across various contexts, and the feasibility of implementing the model across an entire
state (or province).
97.
Fukui, S., Starnino, V. R., Susana, M., Davidson, L. J., Cook, K., Rapp, C. A., &
Gowdy, E. A. (2011). Effect of Wellness Recovery Action Plan (WRAP) participation
on psychiatric symptoms, sense of hope, and recovery. Psychiatric Rehabilitation
Journal, 34(3), 214-222. doi: 10.2975/34.3.2011.214.222.
A study on WRAP impact on recovery-related outcomes (Fukui et al., 2011) was a quasiexperimental trial conducted at five sites in Kansas, which showed that intervention
group members experienced fewer symptoms and greater hopefulness following the
intervention and at six month follow-up. There was no change on recovery, as measured
by the Recovery Markers Scale. The intervention was delivered by a peer educator (who
had been trained in a two-day event) and a psychosocial rehabilitation practitioner,
using sessions of approximately 1.5 to 2 hrs, in groups that were initially between four
and twelve members.
Implications: The results suggest that peer-led WMR/IMR interventions can be useful
complement to other evidence-based recovery-oriented supports. The authors suggest
also that the impacts of these interventions could be improved if they were integrated
more closely with formal supports.
98.
Cook, J. A., Copeland, M. E., Jonikas, J. A., Hamilton, M. M., Razzano, L. A., Grey, D.
D., . . . Boyd, S. (2011). Results of a randomized controlled trial of mental illness selfmanagement using Wellness Recovery Action Planning. Schizophrenia Bulletin.
doi:10.1093/schbul/sbr012.
Cook, Copeland, Jonikas et al. (2011) present the first RCT of the WRAP intervention
which shows that compared to a waitlist control, the approximately 260 test group
participants significantly reduced symptom levels, improved hopefulness, and
improved their quality of life over time. These results were still significant at six-month
follow-up.
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Implications: This study suggests that the WRAP program, implemented in all fifty
states and in some Canadian provinces, and in use for the past several years, can achieve
wellness management outcomes and contribute to recovery. This peer led intervention
appears to be on track to be considered an evidence-based practice. The results are
consistent with peer-delivered self-management related interventions for other health
conditions (e.g. the Chronic Disease Self Management Program, Bodheimer, Lorig & et
al., (2002)) which appear to achieve outcomes at least in part via positive social
comparisons and self-efficacy beliefs through behaviour and results modelled by similar
others.
99.
Jonikas, J. A., Grey, D. D., Copeland, M. E., Razzano, L. A., Hamilton, M. M., Floyd, . .
. Cook, J. A. (2011). Improving propensity for patient self-advocacy through wellness
recovery action planning: Results of a randomized controlled trial. Community Mental
Health Journal. Advanced online publication. doi: 10.1007/s10597-011-9475-9.
An RCT of WRAP impact on patient self-advocacy (Jonikas et al., 2012) found the
intervention to have greater impact on patient self-advocacy, which in turn was related
to greater hopefulness, fewer psychiatric symptoms, and higher environmental quality
of life.
Implications: Taken together with the Cook, Steigman et al.’s (2012), RCT study, the
results suggest that peer-led IMR interventions would be a useful part of a full array of
recovery-oriented supports.
100.
Cook, J. A., Steigman, P., Pickett, S., Diehl, S., Fox, A., Shipley, P., . . . Burke-Miller, J.
K. (2012). Randomized controlled trial of peer-led recovery education using Building
Recovery of Individual Dreams and Goals through Education and Support
(BRIDGES). Schizophrenia Research, 136(13), 36-42. doi: 10.1016/j.schres.2011.10.016.
Cook, Steigman et al. (2012) reported on the results of a multi-site trial in Tennessee, of
the Building Recovery of Individual Dreams and Goals through Education and Support,
which compared to a waitlist control found higher self-perceived recovery on a number
of dimensions, as well as improved hopefulness (agency) at program completion and
six-month follow-up. These impacts were found in people with co-occurring depression
but to a lesser degree. Like WRAP, the intervention is taught by a certified peer
educator in eight sessions, lasting 2.5 hours, in groups of 4-13 people, using curriculum
based information, structured exercises, personal anecdotes and group discussion to
illustrate and process the concepts. Along with basic mental health-related treatment
information (traditional and non-traditional), and material about preventing relapse and
coping skills, building social and community support systems, the content includes
information about the recovery process, as well as structured problem solving and
communications skills. Instructors received backup support from clinical leaders to deal
with group process issues, and a backup teacher was available for emergencies.
Implications: This, the second successful RCT trial of a peer-led WMR/IMR
intervention demonstrates that well implemented peer led interventions can impact
significantly on illness management and recovery-related outcomes.
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101.
Barbic, S., Krupa, T., & Armstrong, I. (2009). A randomized controlled trial of the
effectiveness of a modified recovery workbook program: Preliminary findings.
Psychiatric Services, 60(4), 491-497. doi: 10.1176/appi.ps.60.4.491.
Barbic, Krupa, and Armstrong (2009) conducted a randomized controlled trial of the
Boston Center for Psychiatric Rehabilitation’s Recovery Workbook; the intervention was
shortened from the recommended 40 weeks, to 12 two-hour sessions conducted once a
week by a peer support worker (a paid worker of an ACT team) and an occupational
therapist, and offered in groups of seven to nine, to members of an Assertive
Community Treatment Team in Kingston, ON. Like the WRAP program, the Recovery
Workbook offers information and skills, provides education about the recovery process
and strategies, and helps participants develop an action plan. Though the intervention
was shortened, all topics in the original curriculum were covered, and delivered through
a mixture of instruction, discussion, and practice exercises. Immediately after
completion of the intervention, the study found significant increases in hopefulness,
empowerment, and aspects of recovery, as measured by the Recovery Assessment Scale
(RAS).
Implications: This trial shows that there a number of promising options for delivering
IMR/WMR interventions which appear to promote recovery, and in which peers are
involved as educators.
102.
Druss, B. G., Zhao, L., von Esenwein, S. A., Bona, J. R., Fricks, L., Jenkins-Tucker, S., . .
. Lorig, K. (2010). The Health and Recovery Peer (HARP) program: A peer-led
intervention to improve medical self-management for persons with serious mental
illness. Schizophrenia Research, 118(1-3), 264-270. doi:10.1016/j.schres.2010.01.026.
Druss et al. (2010) present the results of an RCT of the Health and Recovery Program
(HARP), an adaptation of the Stanford Chronic Disease Self Management Program
(CDSMP) for people with serious mental illness and other co-morbid conditions. The
study found a relative advantage in terms of patient activation, and use of primary care
health care at six-month follow-up. Though not statistically significant, the intervention
participants tended to have, physical activity, physical health related quality of life, and
greater adherence to treatment.
Implications: This peer-led program shows promise, and may be another opportunity to
effectively engage the peer workforce.
103.
Lawn, S., Battersby, M. W., Pols, R. G., Lawrence, J., Parry, T., & Urukalo, M. (2007).
The mental health expert patient: Findings from a pilot study of a generic chronic
condition self-management programme for people with mental illness. International
Journal of Social Psychiatry, 53(1), 63-74. doi: 10.1177/0020764007075010.
Lawn et al. (2007) implemented the Stanford CDMSP program for people with serious
mental illness (the largest subgroup of whom had first episode psychosis). Participants’
self-management abilities and preferences were assessed by a case manager in a primary
care setting, and then offered collaborative care structured problem solving approach,
and either the Stanford model or 1:1 peer-based self management training. The pilot
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project showed increases in self-management ability and mental functioning at sixmonth follow-up.
Implications: Despite implementation challenges, a self-management intervention
involving both the primary care and mental health sectors can improve selfmanagement ability of people with serious mental illness.
Implementing IMR-related interventions within real-world service settings
104.
Levitt, A. J., Mueser, K. T., DeGenova, J., Lorenzo, J., Bradford-Watt, D., Barbosa, A., . .
. Chernick, M. (2009). Randomized controlled trial of illness management and
recovery in multiple-unit supportive housing. Psychiatric Services, 60(12), 1629-1636.
doi: 10.1176/appi.ps.60.12.1629.
A paper reporting on the results of an RCT of IMR in multi-unit supportive housing
(Levitt et al., 2009) described how the IMR approach was implemented in a group
format (of approximately 7 or 8 participants) by a housing agency for its clients, and
showed significant improvements in self and clinician rated self-management ability, in
symptoms, and in psychosocial functioning. There was no impact on rehospitalisation or
on substance use, which were relatively low to begin with. There was a relatively high
drop out rate (approximately 50%) which post-hoc focus groups indicated were due to
the content being viewed as too basic for some participants, who already had a
significant degree of knowledge about their illness and how to manage it.
Implications: The IMR model can be implemented in routine mental health settings,
such as housing agencies. Facilitators need to be cognizant that group members are at
similar baseline levels of knowledge and self-management ability. [As suggested earlier,
this may be harder to accomplish with larger groups of participants.]
105.
Salyers, M. P., Godfrey, J. L., McGuire, A. B., Gearhart, T., Rollins, A. L., & Boyle, C.
(2009). Implementing the illness management and recovery program for consumers
with severe mental illness. Psychiatric Services, 60(4), 483-490. doi:
10.1176/appi.ps.60.4.483.
Salyers, Godfrey et al. (2009) examined implementation in seven sites in one state, and
demonstrated that it is feasible to implement the model with high fidelity. It generally
took one year to achieve these fidelity levels, which were achieved through initial
training sessions, supervision, group leader teleconferences supervised by a trainer, and
fidelity site visits. This pre-post evaluation demonstrated similar results as found in the
published trials (Hasson-Ohayon et al., 2011; Färdig et al., 2011) finding increases in
self-management ability, but not in hope or satisfaction with other services. The authors
also discuss some key implementation challenges.
Implications regarding implementation challenges: On the basis of their experience the
authors suggest that given the amount of material, that the group-based format using
approximately 4 participants may be most feasible. Attempts to include 7 or 8, as
recommended initially, may be less feasible, given that the intervention seeks to address
individually set life goals of each of its participants. They also suggest that sites start
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with one pilot project rather than attempt to implement the model on a broad scale right
away. Another recommendation is for programs to internalize the fidelity monitoring
and outcome measurement functions, rather than continue to rely on outside technical
assistance support.
106.
Michon, H. W. C., van Weeghel, J., Kroon, H., & Schene, A. H. (2011). Illness selfmanagement assessment in psychiatric vocational rehabilitation. Psychiatric
Rehabilitation Journal, 35(1), 21-27. doi: 10.2975/35.1.2011.21.27.
Michon, van Weeghel, Kroon, and Shene (2011) suggest that illness management ability
may improve vocational outcomes, and present data on an assessment scale that holds
promise as an adjunct to vocational assessment which may help participants identify
and address illness-related barriers in the workplace.
Implications: Assessing and addressing work-specific illness management barriers may
help consumers find and maintain employment.
107.
Salerno, A., Margolies, P., Cleek, A., Pollock, M., Gopalan, G., & Jackson, C. (2011).
Wellness self-management: An adaptation of the illness management and recovery
program in New York state. Psychiatric Services, 62(5), 456-458. doi:
10.1176/appi.ps.62.5.456.
Salerno et al. (2011) described the initiative of New York State to adapt the IMR
approach. The main changes were to add material that was more “wellness” focussed,
and to adapt the approach (originally designed as an individual intervention) to the
group format by developing a participant workbook, a specific group facilitation
approach, and developing a process for helping participants set individual action steps
to accomplish personal goals. Across all the approximately 100 programs, about 400
participants identified individualized goals at baseline, and at the end of treatment had
made significant progress towards achieving 75% of these.
Implications: A structured, easy to implement facilitation process and individualized
workbook can help jurisdictions adapt the IMR intervention for their own purposes. The
IMR intervention can be made more “wellness” focussed by adding a module focussing
on physical health.
108.
Whitley, R., Gingerich, S., Lutz, W. J., & Mueser, K. T. (2009). Implementing the
illness management and recovery program in community mental health settings:
Facilitators and barriers. Psychiatric Services, 60(2), 202-209. doi:
10.1176/appi.ps.60.2.202.
Whitley, Gingerich, Lutz, and Mueser (2009) describe a study of implementation of IMR,
which showed four factors that contributed: leadership, at multiple-levels (jurisdiction,
agency and program), and where the work of the various leaders was synergistic;
organizational culture: marked by agencies that had implemented innovative practices in
the recent past and saw the IMR project as an opportunity to facilitate recovery, rather
than something that took resources away from organizational concerns about
maintaining the status quo or survival; training, from a well-respected competent
individual is necessary for strong implementation, but appears to require the presence of
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strong leadership and organizational culture to succeed; and staffing and supervision from
individuals who had developed similar skills and who were “bought in” to the value of
illness management and recovery; low fidelity sites expressed concerns about perceived
program shortcomings (e.g. dense material) while higher fidelity sites were able to work
around these.
Wellness & Lifestyle Interventions – Reviews
109.
Faulkner, G., Cohn, T., & Remington, G. (2007). Interventions to reduce weight gain
in schizophrenia. Schizophrenia Bulletin, 33(3), 654-656. doi: 10.1093/schbul/sbm022.
Faulkner, Cohn, and Remington (2010) reported on a Cochrane Review looking at
weight loss interventions for people with serious mental illness, and found that CBT and
pharmacological adjunct therapy both prevented wait gain compared to a control group.
The review also found that CBT was effective in helping people lose weight.
Implications: Both psychosocial and pharmacological interventions can have modest
impacts in terms of preventing weight gain, and psychosocial interventions can achieve
weight loss, which may have an impact with respect to preventing diabetes, stroke, and
heart disease.
110.
Gorczynski, P., & Faulkner, G. (2010). Exercise therapy for schizophrenia. Cochrane
Database of Systematic Reviews, (5). doi: 10.1002/14651858.CD004412.pub2.
Gorczynski and Faulkner (2011) review the health benefits of exercise for people with
schizophrenia. The results of this Cochrane review are similar to existing reviews that
have examined this issue. Although studies included in this review are small and used
various measures of physical and mental health, results indicated that regular exercise
programmes are possible, and that they can have healthful effects on both the physical
and mental health and well-being of individuals with schizophrenia. Larger randomised
studies are required before any definitive conclusions can be drawn.
Implications: Exercise-related interventions can be implemented and can benefit the
physical and mental health of people with serious mental illness.
111.
Kisely, S., Quek, L.-H., Pais, J., Lalloo, R., Johnson, N. W., & Lawrence, D. (2011).
Advanced dental disease in people with severe mental illness: systematic review and
meta-analysis. The British Journal of Psychiatry, 199(3), 187-193. doi:
10.1192/bjp.bp.110.081695.
Kisely et al. (2011) show that people with serious mental illness have disproportionate
rates of advanced dental disease.
Implications: People with serious mental illness should have access to oral hygiene and
management of dental psychiatric medication side-effects integrated into regular care.
112.
Tsoi, D. T., Porwal, M., & Webster, A. C. (2010). Interventions for smoking cessation
and reduction in individuals with schizophrenia. Cochrane Database of Systematic
Reviews. doi: 10.1002/14651858.CD007253.pub2.
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A Cochrane Review of a smoking cessation intervention for people with schizophrenia
(Tsoi, Porwal, & Webster, 2011) suggests that Bupropion increases smoking abstinence
rates in smokers with schizophrenia, without jeopardising their mental state. Bupropion
may also reduce the amount these patients smoke. Contingency reinforcement with
money may help this group of patients to quit and reduce smoking. The authors failed
to find convincing evidence that other interventions have a beneficial effect on smoking
behaviour in schizophrenia.
Implications: There are helpful interventions to offer people with schizophrenia who
wish to quit smoking, which can be integrated into their regular healthcare.
Integrated Dual Diagnosis Treatment (IDDT) and Psychosocial
Interventions
113.
Drake, R. E., O'Neal, E. L., & Wallach, M. A. (2008). A systematic review of
psychosocial research on psychosocial interventions for people with co-occurring
severe mental and substance use disorders. Journal of Substance Abuse Treatment,
34(1), 123-138. doi: 10.1016/j.jsat.2007.01.011.
A review of integrated dual diagnosis treatment and psychosocial interventions (IDDT)
(Drake, O'Neal, & Wallach, 2008), showed that a number of interventions (group
counselling, contingency management, and residential dual diagnosis treatment) were
effective for helping participants manage substance use disorder.
Implications: Integrated Dual Diagnosis Treatment (IDDT) has a large and
heterogeneous evidence base which supports several forms of interventions. More
research is required regarding staging of the interventions, and determining which
interventions work for which subgroup.
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59
114.
Cleary, M., Hunt, G. E., Matheson, S., & Walter, G. (2009). Psychosocial treatments for
people with co-occurring severe mental illness and substance misuse: Systematic
review. Journal of Advanced Nursing, 65(2), 238-258. doi:10.1111/j.13652648.2008.04879.x.
A Cochrane Review of psychosocial interventions for PWDD (Cleary, Hunt, Matheson,
& Walter, 2009) found no difference between various approaches (integrated case
management, non-integrated case management, motivational interviewing, CBT) and
care as usual.
Implications: There is no evidence supporting any particular approach to IDDT,
although methodological problems prevent proper comparisons of the different
interventions.
115.
Torchalla, I., Nosen, L., Rostam, H., & Allen, P. (2012). Integrated treatment programs
for individuals with concurrent substance use disorders and trauma experiences: A
systematic review and meta-analysis. Journal of Substance Abuse Treatment, 42(1), 6577. doi: 10.1016/j.jsat.2011.09.001.
Torchalla, Nosen, Rostam and Allen (2011) conducted a systematic review of
psychotherapeutic integrated treatment (IT) for individuals with trauma histories and
substance use.
Implications: Both integrated and non-integrated treatment had a positive impact of
trauma symptoms and substance abuse.
Other References
116.
Bodenheimer, T., Lorig, K., Holman, H., & Grumbach, K. (2002a). Patient selfmanagement of chronic disease in primary care. JAMA, 288(19), 2469-2475.
117.
Pekalla, E. & L. Merinder (2002). Psychoeducation for Schizophrenia. Cochrane
Database of Systematic Reviews. 4 (update).
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Kisely, S., Quek, L.-H., Pais, J., Lalloo, R., Johnson, N. W., & Lawrence, D. (2011). Advanced
dental disease in people with severe mental illness: systematic review and metaanalysis. The British Journal of Psychiatry, 199(3), 187-193. doi: 10.1192/bjp.bp.110.081695
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cognitive behavior therapy or social skills training for individuals with a recent onset of
psychosis? Results of a randomized controlled trial. The Journal of Nervous and Mental
Disease, 196(12), 866-875. doi: 10.1097/NMD.0b013e31818ee231
Levitt, A. J., Mueser, K. T., DeGenova, J., Lorenzo, J., Bradford-Watt, D., Barbosa, A., . . .
Chernick, M. (2009). Randomized controlled trial of illness management and recovery in
multiple-unit supportive housing. Psychiatric Services, 60(12), 1629-1636. doi:
10.1176/appi.ps.60.12.1629
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symptoms, knowledge, adherence and functioning in psychotic disorders: A metaanalysis. Schizophrenia Research, 96(1), 232-245. doi: 10.1016/j.schres.2007.07.022
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Delphin-Rittmon, M. E. (2014). Consumer and family psychoeducation: assessing the
evidence. Psychiatr Serv, 65(4), 416-428. doi: 10.1176/appi.ps.201300266
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schizophrenia. Cochrane Database of Systematic Reviews. doi: 10.1002/
14651858.CD003442.pub2
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M. I. (2002). Illness management and recovery: A review of the research. Psychiatric
Services, 53(10), 1272-1284. doi: 10.1176/appi.ps.53.10.1272
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Mueser, K. T., Meyer, P. S., Penn, D. L., Clancy, R., Clancy, D. M., & Salyers, M. P. (2006). The
illness management and recovery program: Rationale, development, and preliminary
findings. Schizophrenia Bulletin, 32(Suppl.1), S32-S43. doi: 10.1093/schbul/sbl022
Pekalla, E. & L. Merinder (2002). Psychoeducation for Schizophrenia. Cochrane Database of
Systematic Reviews. 4 (update).
Pharoah, F., Mari, J., Rathbone, J., & Wong, W. (2010). Family intervention for schizophrenia.
Cochrane Database of Systematic Reviews. doi: 10.1002/14651858.CD000088.pub3
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management and recovery: Participants' accounts of its impact and uniqueness.
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Salerno, A., Margolies, P., Cleek, A., Pollock, M., Gopalan, G., & Jackson, C. (2011). Wellness
self-management: An adaptation of the illness management and recovery program in
New York state. Psychiatric Services, 62(5), 456-458. doi: 10.1176/appi.ps.62.5.456
Salyers, M. P., McGuire, A. B., Kukla, M., Fukui, A., Lysaker, P., & Mueser, K. T. (2014). A
Randomized Controlled Trial of Illness Management and Recovery With an Active
Control Group. Psychiatric Services, 65(8), 1005-1011. doi:
doi:10.1176/appi.ps.201300354
Salyers, M. P., Godfrey, J. L., McGuire, A. B., Gearhart, T., Rollins, A. L., & Boyle, C. (2009).
Implementing the illness management and recovery program for consumers with severe
mental illness. Psychiatric Services, 60(4), 483-490. doi: 10.1176/appi.ps.60.4.483
Salyers, M. P., McGuire, A. B, Rollins, A. L., Bond, G. R., Mueser, K. T., & Macy, V. R. (2010).
Integrating assertive community treatment and illness management and recovery for
consumers with severe mental illness. Community Mental Health Journal, 46(4), 319-329.
doi: 10.1007/s10597-009-9284-6
Salyers, M. P., Rollins, A. L., Clendenning, D., McGuire, A. B., & Kim, E. (2011). Impact of illness
management and recovery programs on hospital and emergency room use by medicaid
enrollees. Psychiatric Services, 62(5), 509-515. doi: 10.1176/appi.ps.62.5.509
Sterling, E. W., von Esenwein, S. A., Tucker, S., Fricks, L., & Druss, B. G. (2010). Integrating
wellness, recovery, and self-management for mental health consumers. Community
Mental Health Journal, 46(2), 130-138. doi: 10.1007/s10597-009-9276-6
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Torchalla, I., Nosen, L., Rostam, H., & Allen, P. (2012). Integrated treatment programs for
individuals with concurrent substance use disorders and trauma experiences: A
systematic review and meta-analysis. Journal of Substance Abuse Treatment, 42(1), 65-77.
doi: 10.1016/j.jsat.2011.09.001
Tsoi, D. T., Porwal, M., & Webster, A. C. (2010). Interventions for smoking cessation and
reduction in individuals with schizophrenia. Cochrane Database of Systematic Reviews. doi:
10.1002/14651858.CD007253.pub2
Whitley, R., Gingerich, S., Lutz, W. J., & Mueser, K. T. (2009). Implementing the illness
management and recovery program in community mental health settings: Facilitators
and barriers. Psychiatric Services, 60(2), 202-209. doi: 10.1176/appi.ps.60.2.202
Wykes, T., Steel, C., Everitt, B., & Tarrier, N. (2008). Cognitive behavior therapy for
schizophrenia: Effect sizes, clinical models, and methodological rigor. Schizophrenia
Bulletin, 34(3), 523-537. doi: 10.1093/schbul/sbm114
Xia, J., Merinder, L. B., Belgamwar, M. R. (2011). Psychoeducation for schizophrenia. Cochrane
Database of Systematic Reviews. doi: 10.1002/14651858.CD002831.pub2
Wellness Management & Recovery Interventions
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Life & Leisure Skills
General Life Skills (and General Skill Building)
118.
Lyman, D. R., Kurtz, M. M., Farkas, M., George, P., Dougherty, R. H., Daniels, A. S., . .
. Delphin-Rittmon, M. E. (2014). Skill building: assessing the evidence. Psychiatr Serv,
65(6), 727-738. doi: 10.1176/appi.ps.201300251
Skill building involves multiple approaches to address the complex problems related to
serious mental illness. The authors of this paper outline key skill-building approaches
and review their evidence base, characterizing the evidence as strong, mixed, or low.
They found 100 randomized controlled trials and numerous quasi-experimental studies,
and rated the level of evidence as high. Outcomes indicate strong effectiveness for social
skills training, social cognitive training, and cognitive remediation, especially if these
interventions are delivered through integrated approaches, such as Integrated
Psychological Therapy (see below). Results are somewhat mixed for life skills training
(when studied alone) and cognitive-behavioral approaches. The complexities of
schizophrenia and other serious mental illnesses call for individually tailored,
multimodal skill-building approaches in combination with other treatments.
Implications: Skill building should be a foundation for rehabilitation for multicomponent service packages delivered in various combinations tailored to individual
need. Further research should demonstrate more conclusively the long-term
effectiveness of skill building in real-life situations, alone and in various treatment
combinations. Studies of diverse subpopulations are also needed.
119.
Tungpunkom, P., Maayan, N., & Soares-Weiser, K. (2012). Life skills programmes for
chronic mental illnesses. Cochrane Database of Systematic Reviews, (1), doi:
10.1002/14651858.CD000381.pub3.
Tungpunkom, Maayan and Soares-Weiser (2011) carried out a Cochrane Review
comparing life skills interventions, standard care, and support groups; they found no
significantly different impact on social performance, quality of life, or symptomatology.
Implications: This review does not describe any of the interventions categorized as “life
skills” interventions, so it is difficult to ascertain the implications of the paper; however,
providing life skills training appears to offer no advantage when compared to regular
community care.
120.
Gibson, R. W., D'Amico, M., Jaffe, L., & Arbesman, M. (2011). Occupational therapy
interventions for recovery in the areas of community integration and normative life
roles for adults with serious mental illness: A systematic review. The American
Journal of Occupational Therapy, 65(3), 247-256. doi: 10.5014/ajot.2011.001297.
Gibson, D'Amico, Jaffe and Arbesman (2011) carried out a systematic review that looked
at OT interventions for enhancing skills and performance in “normative roles”, finding
that the evidence for social skills training (SST) was strong, whereas the evidence for life
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skills/activities of daily living (ADL)-related interventions is moderate, as was the
evidence for neurocognitive + skill training in the areas of work, social participation, and
ADL’s.
Implications: SST can improve social performance, ADL training can help with activities
of daily living, but in and of themselves life skill/ADL-related interventions and
neurocognitively-oriented skill training do not appear effective for improving
performance of normative life roles in the longer term. As discussed elsewhere in this
bibliography, however, all of these interventions (neurocognitive skill training, SST, and
other life skills interventions) may be useful adjuncts to supported employment and/or
supported education. OT’s may have to diversify their traditional focus on assessment
and skill building towards the complementary task of identifying and developing
supports in the work environment.
Life & Leisure Skills
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Social Skills Training
121.
Pilling, S., Bebbington, P., Kuipers, E., Garety, P., Geddes, J., Martindale, B., . . .
Morgan, C. (2002). Psychological treatments in schizophrenia: II. Meta-analyses of
randomized controlled trials of social skills training and cognitive remediation.
Psychological Medicine, 32(05), 783-791. doi: 10.1017/S0033291702005640.
Pilling et al. (2002) conducted a meta-analytical review of social skills training
interventions (SST), and cognitive remediation, comparing these to other “active
interventions” and standard care. They found no relative benefit for SST on relapse rate,
global adjustment, social functioning, quality of life or treatment compliance. Cognitive
remediation had no benefit on attention, verbal memory, visual memory, planning,
cognitive flexibility or mental state.
Implications: The authors’ conclusion is that these interventions are not recommended
given the current state of evidence.
122.
Kurtz, M. M., & Mueser, K. T. (2008). A meta-analysis of controlled research on social
skills training for schizophrenia. Journal of Consulting and Clinical Psychology, 76(3),
491-504. doi: 10.1037/0022-006X.76.3.491.
Kurtz and Mueser (2008) conducted a meta-analysis of social skills training
interventions (SST), examining effect sizes of SST on proximal, medial and distal
outcomes, but not comparing these to those produced by standard care other active
interventions that might be comparable. They found a strong effect on content-mastery,
a moderate effect on performance-based measures of ADL and role performance, a
moderate effect on community functioning and negative symptoms, and a small effect
on other symptoms and relapse.
Implications: SST helps people with serious mental illness perform the activities of
daily living, and improves general community functioning and thus should be
considered as an aspect of a comprehensive psychosocial rehabilitation approach. It may
also be helpful for illness management.
123.
Roder, V., Mueller, D. R., Mueser, K. T., & Brenner, H. D. (2006). Integrated
Psychological Therapy (IPT) for schizophrenia: Is it effective? Schizophrenia Bulletin,
32(Suppl. 1), S81-S93. doi: 10.1093/schbul/sbl021.
Roder, Mueller, Mueser, and Brenner (2006) reviewed seven high-quality studies of
Integrated Psychological Therapy (IPT), an intervention that combines traditional SST
with an approach that targets cognitive (including social cognitive) function, and found
that compared to standard care, IPT achieved superior “global therapy outcomes”, as
well as superior neurocognition, psychopathology improvement scores, and
psychosocial functioning, which were maintained eight months later, across all outcome
domains and assessment formats, for a variety of participant populations at various
stages in their illness.
Implications: This manualized five-module group-based intervention significantly helps
the interpersonal problem-solving ability and social competence of persons with serious
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mental illness and thus should be considered as part of a comprehensive psychosocial
rehabilitation approach. Unlike computer-based cognitive remediation approaches that
help participants process “cold cognitions”, in the IPT approach cognitive remediation is
carried out in an interactive fashion and in conjunction with social problem solving. This
may account for the differences in findings between this review and that conducted by
Pilling et al.’s (2002), which was not as supportive of cognitive remediation approaches.
The IPT intervention has largely been implemented in European settings. Thus, there are
questions surrounding its generalizability to a Canadian context, and about
implementation, given its unfamiliarity here. However, as described elsewhere in this
bibliography (see Eack et als. 2009, under Supported Employment), a recent RCT of a
similar approach known as Cognitive Enhancement Therapy (CET) for participants with
“early course schizophrenia” showed similar results in terms of social role performance,
and showed significant improvements in employment-related outcomes, even though
the intervention did not directly target employment status.
124.
Reddon, J. R., Hoglin, B., & Woodman, M.-A. (2008). Immediate effects of a 16-week
life skills education program on the mental health of adult psychiatric patients. Social
Work in Mental Health, 6(3), 21-40. doi:10.1300/J200v06n03_02.
Reddon, Hoglin, and Woodman (2008) report on the results of a pre-post evaluation of a
Canadian intervention that addresses social perception, interpersonal communication,
problem-solving, and self/emotional awareness, which showed improvements in
depression, and in “psychiatric and social symptomatology” (which measures
psychosocial adjustment), though only for women.
Implications: Though only suggestive in and of itself, this study is consistent with and
thus reinforces the conclusions of the evidence presented above suggesting that social
cognitively-oriented interventions should be part of an overall approach to psychosocial
rehabilitation, and also suggests that these interventions can successfully implemented
in a Canadian context.
Social Skills Training and other Psychosocial Rehabilitation Approaches in
Older Populations
125.
Pratt, S. I., Van Citters, A. D., Mueser, K. T., & Bartels, S. J. (2008). Psychosocial
rehabilitation in older adults with serious mental illness: A review of the research
literature and recommendations for development of rehabilitative approaches.
American Journal of Psychiatric Rehabilitation, 11(1), 7-40. doi:
10.1080/15487760701853276.
Pratt, Van Citters, Mueser, and Bartels (2008) review the literature pertaining to
psychosocial rehabilitation approaches for older adults. The results suggest that specific
interventions that help independent living skills and social skills which “hold promise”
for older populations include Functional Adaptation Skills Training (FAST), CognitiveBehavioural Social Skills Training (CBSST) and Skills Training and Health Management
(ST + HM). The FAST intervention is based on social learning theory and is a 24-week
modularlized program which addresses illness management, skill-training for Activities
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of Daily living, and communication skills. Two RCTs of the intervention have been
conducted, including one adapting the intervention for the Latino community, and
showed improved negative symptoms and improvements in performance-based
measures of the community functioning, but no “real world” outcomes were measured.
CBSST combines social skills training and CBT for persistent symptoms using cognitive
restructuring techniques. Two RCTs have been conducted which demonstrated
improvements in cognitive insight about symptoms (but not symptoms themselves), and
some aspects of social functioning (leisure and transportation skills), though no
measures were conducted in actual community settings. ST + M combines traditional
SST and health management (see the next abstract for a fuller description of the
intervention). One RCT has demonstrated improvements in general health outcomes
(e.g. connection to primary care physicians, improved health prevention) and
improvements in performance-based social and community functioning. Implications:
Psychosocial interventions combining SST, wider life skills, and illness management
approaches including CBT should be considered for older people with serious mental
illness. A number of rehabilitative interventions hold promise and should be considered,
as should other proven rehabilitation approaches such as Supported Employment and
medication adherence-related interventions. Decision-makers should also consider
implementing these in the context of service delivery formats such as Assertive
Community Treatment or Intensive Case Management. For further consideration of
how such interventions could be implemented within various Canadian service
delivery, system and community contexts, decision-makers should consult McCourt et
al.’s (2011), who on behalf of the Mental Health Commission of Canada have produced a
comprehensive report on recovery-oriented supports for seniors with or at risk of
serious mental illness and mental health issues.
126.
Mueser, K. T., Pratt, S. I., Bartels, S. J., Swain, K., Forester, B., Cather, C., & Feldman, J.
(2010). Randomized trial of social rehabilitation and integrated health care for older
people with severe mental illness. Journal of Consulting and Clinical Psychology,
78(4), 561-573. doi: 10.1037/a0019629.
Mueser et al. (2010) present the results of three-site RCT of the group-based HOPES
program, a year-long social rehabilitation intervention (with a one year maintenance
phase) for adults over 50 with serious mental illness, which showed, compared to
treatment as usual significant improvements of moderate effect size in performancerelated measures of social skill, psychosocial and community functioning, negative
symptoms, and self-efficacy. Psychosocial functioning improvements included an
improvement in the use of recreational and leisure performance, two areas which are
directly addressed by the intervention. The intervention is delivered in modules to
approximately 6-8 people, and is based on standardized SST approaches in terms of its
curriculum (communication, making friends, using leisure time effectively, healthy
living, using medications effectively, and making the most of a healthcare visit) and its
approach (information, skill practice, role play and feedback, homework), with a specific
focus on a broader health concerns and on use of leisure/recreational skills.
Implications: This study shows that existing social/life skills training approaches can be
successfully adapted for older adults and can provide benefits in psychosocial
functioning, including use of leisure and recreational time. The intervention may also
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improve general health management, but more study using more appropriate measures
would be needed to ascertain this. The psychosocial functioning performance scales on
which participants reported improvement are predictive of ongoing real world role
performance, so no firm conclusions can be drawn about these longer term outcomes.
Home-Management Skills
127.
Hellrich, C. A., Chan, D. V., & Sabol, P. (2011). Cognitive predictors of life skill
intervention outcomes for adults with mental illness at risk for homelessness. The
American Journal of Occupational Therapy, 65(3), 277-286. doi: 10.5014/ajot.2011.001321.
Hellrich, Chan, and Sabol (2011) present results of a skill training intervention targeted
at participants with mental illness who are at risk of becoming homeless. Using a prepost design they showed significant improvements in self-care, room management, and
money-management.
Implications: The results of this study, which represents the traditional approach to
housing-related rehabilitation, should be considered in the context of the wider
literature on supported housing. This is because, as was the case with supported
employment, traditional approaches to home-management skill training (or other rolerelated training) though helpful for housing or other role-related performance, do not
appear sufficient to significantly improve participants’ prospects of maintain their
housing.
Money-Management Skills
128.
Elbogen, E. B., Tiegreen, J., Vaughan, C., & Bradford, D. W. (2011). Money
management, mental health, and psychiatric disability: A recovery-oriented model for
improving financial skills. Psychiatric Rehabilitation Journal, 34(3), 223-231. doi:
10.2975/34.3.2011.223.231.
Elbogen, Tiegreen, Vaughan, and Bradford (2011) review the literature on money
management.
Implications: In consideration of the results of clinical case studies, published studies,
and general articles on financial literacy, they suggest that money management
approaches should be incorporated into the psychosocial rehabilitation toolbox, and can
improve: knowledge about and access to disability benefits, basic financial skills, and
protection from financial exploitation. The approaches should be done in a way that
enhances self-determination.
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71
129.
Elbogen, E. B., Wilder, C., Swartz, M. S., & Swanson, J. W. (2008). Caregivers as money
managers for adults with severe mental illness: How treatment providers can help.
Academic Psychiatry, 32(2), 104-110. doi:10.1176/appi.ap.32.2.104.
Elbogen, Wilder, Swartz, and Swanson (2008) review the issue of caregiver involvement
in money management.
Implications: Case managers should be aware of whether caregivers are involved in
money management and take steps to minimize the downsides (e.g. conflict between
consumers and families, dependence, etc.) and potentiate the upsides of this situation.
They can do so by establishing strategies for increased collaboration in money
management, building money management skills in consumers, and making advanced
plans for financial decision-making.
130.
Ries, R. K., Dyck, D. G., Short, R., Srebnik, D., Fisher, A., & Comtois, K. A. (2004).
Outcomes of managing disability benefits among patients with substance
dependence and severe mental illness. Psychiatric Services, 55(4), 445-447.
doi:10.1176/appi.ps.55.4.445.
Ries et al. (2004) report the RCT trial results of a contingency-management approach for
paying disability benefits for people with mental illness with recent cocaine or opiate
use. Compared to a non-contingent approach (i.e. where participants are paid regardless
of substance use, the contingent approach showed better money management, and used
significantly less alcohol and drugs. Participants found this voluntary intervention
useful.
Implications: Using contingency management may help participants become better
money managers and also may have some positive impact on illness (and addictions)
management outcomes.
131.
Rosen, M.I., Carroll, K. M., Stefanovics, E., & Rosenheck, R. A. (2009). A randomized
controlled trial of a money management-based substance use intervention.
Psychiatric Services, 60(4), 498-504. doi: 10.1176/appi.ps.60.4.498.
Rosen, Carroll, Stefanovics, and Rosenheck (2009) report the RCT trial results of a
motivational money management approach, known as ATM (Advisor-Teller) for people
with mental illness and addictions. This is a voluntary intervention where a money
manager stores the individual’s money (chequebooks, cards, money, etc.), and spending
is linked to participants’ self-defined goals. Compared to the control conditions,
participants in the intervention group showed greater reductions in addiction severity,
and better money management.
Implications: Motivational interventions show promise in helping clients with
concurrent mental illness and substance use disorders improve money management and
illness/substance use management.
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Supported Housing
132.
Rog, D. J., Marshall, T., Dougherty, R. H., George, P., Daniels, A. S., Ghose, S. S., &
Delphin-Rittmon, M. E. (2014). Permanent supportive housing: assessing the
evidence. Psychiatr Serv, 65(3), 287-294. doi: 10.1176/appi.ps.201300261
Permanent supportive housing provides safe, stable housing for people with mental and
substance use disorders who are homeless or disabled. This article describes permanent
supportive housing and reviews research through 2012, rating it has high moderate or
low. The review found that the level of evidence for permanent supportive housing was
moderate. Substantial literature, including seven randomized controlled trials,
demonstrated that components of the model reduced homelessness, increased housing
tenure, and decreased emergency room visits and hospitalization. Results were stronger
for studies that compared permanent supportive housing with treatment as usual or no
housing rather than with other models.
Implications: The moderate level of evidence indicates that permanent supportive
housing is promising, but research is needed to clarify the model and determine the
most effective elements for various subpopulations. Policy makers should consider
including permanent supportive housing as a covered service for individuals with
mental and substance use disorders
133.
Chilvers, R., Macdonald, G., & Hayes, A. (2006). Supported housing for people with
severe mental disorders. Cochrane Database of Systematic Reviews. doi:
10.1002/14651858.CD000453.pub2.
Chilvers, Macdonald, and Hayes (2010) performed a Cochrane review looking at
supported and supportive housing and found that more high quality evidence is needed
to draw firm conclusions.
Implications: Supportive housing (i.e., housing with built-in support) may provide a
“safe haven” for people with serious mental illness that improves community tenure.
These benefits, however, need to be weighted against the potential for creating
dependence on mental health services.
134.
Leff, H. S., Chow, C. M., Pepin, R., Conley, J., Allen, I. E., & Seaman, C. A. (2009).
Does one size fit all? What we can and can't learn from a meta-analysis of housing
models for persons with mental illness. Psychiatric Services, 60(4), 473-482. doi:
10.1176/appi.ps.60.4.473.
Leff et al. (2009) conducted a meta-analysis which compared model (supported and
supportive, i.e. residential care and treatment) and non-model housing, looking at
satisfaction, housing stability, symptom reduction and rehospitalisation. Model housing
differed significantly from non-model housing on all outcomes. Residential care and
treatment was superior to non-model housing with respect to symptom reduction;
supported housing was associated with greater satisfaction and with greater housing
stability than non-model housing (though this latter finding was not statistically
significant).
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Implications: Both supportive and supported housing offer benefits in terms of housing
stability, symptom reduction and rehospitalisation, though permanent supported
housing may be more preferred.
135.
Nelson, G., Hall, G. B., & Forchuk, C. (2003). Current and preferred housing of
psychiatric consumers/survivors. Canadian Journal Of Community Mental Health, 22
(1), 5-19. Retrieved from http://www.cjcmh.com/.
Nelson, Hall, and Forchuk (2003) showed that while 79% of people with serious mental
illness preferred independent apartments (supported housing), 73% of the sample were
in some other form of housing.
Implications: Current housing options generally do not correspond with the preferences
of people with serious mental illness, in one Ontario region. This finding is consistent
with research from other areas.
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74
136.
Grant, J. G., & Westhues, A. (2010). Choice and outcome in mental health supported
housing. Psychiatric Rehabilitation Journal, 33(3), 232-235. doi:
10.2975/33.3.2010.232.235.
Grant and Westhues (2010) examined differences in outcomes (health, mental health,
mastery, and social support satisfaction) in high vs. low-support housing settings. Both
groups improved on most outcomes over the study period, and there were no
differences between study groups. Differences appear to be more attributable to choice
over housing, than to level of support.
Implications: In terms of supporting people with serious mental illness to live
successfully in the community, choice over living environment appears to be an
important contributor, irrespective of level of support.
137.
Siegel, C. E., Samuels, J., Tang, D.-I., Berg, I., Jones, K., & Hopper, K. (2006). Tenant
outcomes in supported housing and community residences in New York city.
Psychiatric Services, 57(7), 982-991. doi:10.1176/appi.ps.57.7.982.
Siegel et al. (2006) examined housing tenure associated with different models of housing
provision (supported housing and community residential facilities) for previously
homeless people with serious mental illness with similar illness characteristics and
homeless histories. The study found that substantial proportions of people remained
housed over the study period (18 months) regardless of the housing type. The supported
housing group showed greater autonomy but some struggled with social isolation.
Regardless of housing type, the presence of depression or anxiety at entry was
associated with poorer housing outcomes.
Implications: Supported housing is a viable entry point into housing for previously
homeless people with mental illness, even for people whose histories would suggest
they would more appropriately be placed in community residences.
138.
Nelson, G., Aubry, T., & Lafrance, A. (2007). A review of the literature on the
effectiveness of housing and support, assertive community treatment, and intensive
case management interventions for persons with mental illness who have been
homeless. American Journal of Orthopsychiatry, 77(3), 350-361. doi:10.1037/00029432.77.3.350.
Nelson, Aubry, and LaFrance (2007) conducted a systematic review of housing
approaches for previously homeless people with serious mental illness. The review
found that combining supported housing and case management (either intensive case
management or assertive community treatment) was associated with better housing
tenure, and reduced hospitalization.
Implications: This study supports the Housing First model, and suggests that supported
housing with mobile evidence-based care should be provided to people with serious
mental illness who have been homeless.
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75
139.
Nelson, G., Sylvestre, J., Aubry, T., George, L., & Trainor, J. (2007). Housing choice
and control, housing quality, and control over professional support as ontributors to
the subjective quality of life and community adaptation of people with severe mental
illness. Administration and Policy in Mental Health and Mental Health Services
Research, 34(2), 89-100. doi: 10.1007/s10488-006-0083-x.
Nelson, Sylvestre, Aubry, George, and Trainor (2007) examined the hypothesis that
choice/control over housing and support, and over housing quality would be associated
with greater subjective quality of life and with better community adjustment; they also
examined a second hypothesis which was that apartments (i.e. the supported housing
model) would be associated with a greater sense of control. The study found support for
both hypotheses.
Implications: There is some evidence that the supported housing model appears to lead
to better quality of life and better community adjustment.
Leisure/Recreation/Outdoor Education and Therapy
140.
Davidson, L., Shahar, G., Stayner, D. A., Chinman, M. J., Rakfeldt, J., & Tebes, J. K.
(2004). Supported socialization for people with psychiatric disabilities: Lessons from a
randomized controlled trial. Journal of Community Psychology, 32(4), 453-477. doi:
10.1002/jcop.20013.
Davidson et al. (2004) describe a supported socialization and recreation intervention,
which was designed to engage socially isolated individuals in social and recreational
activities by linking them with a volunteer partner who was either an individual with a
history of mental illness or without. The comparison group also received an intervention
but was not linked with a partner. Compared to baseline, all participants showed
improvements in symptoms, functioning and self-esteem, but differences between
groups were significant and were correlated with amount of contact with the volunteer
partner.
Implications: Interventions involving volunteer partners can increase social and
recreational engagement which, in turn can improve symptoms, functioning and selfesteem.
141.
Frances, K. (2006). Outdoor recreation as an occupation to improve quality of life for
people with enduring mental health problems. The British Journal of Occupational
Therapy, 69(4), 182-186. Retrieved from
http://www.ingentaconnect.com/content/cot/bjot.
Frances (2006) discuss outdoor recreation for people with serious mental illness. The
authors make the case that outdoor recreation can be considered as an occupational role,
which if fulfilled can improve self-esteem and wider recovery related outcomes for
people with serious mental illness.
Implications: Taken together these two papers provide some theoretical and empirical
support for the commonly held idea that recreation-specific interventions should be
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developed and implemented, because they can facilitate the social recovery of people
with serious mental illness. More attention should be given to the issue of how
recreational approaches could be combined with other psychosocial rehabilitation
approaches.
Navigating Systems and Services/Accessing Community Services
142.
Anderson, J.E. & Clarke, S.C. (2009). The Sooke Navigator project: using community
resources and research to improve local service for mental health and addictions.
Mental Health in Family Medicine. 6(1), 21-28. doi:
Anderson & Clarke (2009) describe the Sooke Navigator Project, and how a rural BC
community engaged in an innovative action research project to improve access to mental
health and addiction services for citizens and increase connections and communication
between primary care, community-based providers, and the formal mental health
service system. Developed by a community-based steering committee, the Navigator
model is aimed at any person with mental health and addictions issues seeking help in
the Sooke region. The model includes: timely needs assessment, collaborative assistance
with need-based care planning, appropriate information, referral, and linkage
facilitation. Key features of the Navigator model are discussed, including community
engagement, and guiding principles. In this rural and remote community, a communitysupported Navigator model was effective in increasing access to comprehensive,
strengths-based assessment, planning and referral facilitation.
Implications: A joint community effort can increase collaboration between primary care
and formal mental health services, and can help people with mental health and
addictions issues access and navigate appropriate care.
Other References
143.
MacCourt, P., Wilson, K. & Tourigny-Rivard, M.-F. (2011). Guidelines for
Comprehensive Mental Health Services for Older Adults in Canada. Calgary, AB:
MHCC: Retrieved from http://www.mentalhealthcommission.ca .
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References – Life & Leisure Skills
Anderson, J.E. & Larke, S.C. (2009). The Sooke Navigator project: using community resources
and research to improve local service for mental health and addictions. Mental Health in
Family Medicine. 6(1), 21-28. doi:
Chilvers, R., Macdonald, G., & Hayes, A. (2006). Supported housing for people with severe
mental disorders. Cochrane Database of Systematic Reviews. doi:
10.1002/14651858.CD000453.pub2.
Davidson, L., Shahar, G., Stayner, D. A., Chinman, M. J., Rakfeldt, J., & Tebes, J. K. (2004).
Supported socialization for people with psychiatric disabilities: Lessons from a
randomized controlled trial. Journal of Community Psychology, 32(4), 453-477. doi:
10.1002/jcop.20013
Elbogen, E. B., Tiegreen, J., Vaughan, C., & Bradford, D. W. (2011). Money management, mental
health, and psychiatric disability: A recovery-oriented model for improving financial
skills. Psychiatric Rehabilitation Journal, 34(3), 223-231. doi: 10.2975/34.3.2011.223.231
Elbogen, E. B., Wilder, C., Swartz, M. S., & Swanson, J. W. (2008). Caregivers as money
managers for adults with severe mental illness: How treatment providers can help.
Academic Psychiatry, 32(2), 104-110. doi:10.1176/appi.ap.32.2.104
Frances, K. (2006). Outdoor recreation as an occupation to improve quality of life for people
with enduring mental health problems. The British Journal of Occupational Therapy, 69(4),
182-186. Retrieved from http://www.ingentaconnect.com/content/cot/bjot
Gibson, R. W., D'Amico, M., Jaffe, L., & Arbesman, M. (2011). Occupational therapy
interventions for recovery in the areas of community integration and normative life roles
for adults with serious mental illness: A systematic review. The American Journal of
Occupational Therapy, 65(3), 247-256. doi: 10.5014/ajot.2011.001297
Grant, J. G., & Westhues, A. (2010). Choice and outcome in mental health supported housing.
Psychiatric Rehabilitation Journal, 33(3), 232-235. doi: 10.2975/33.3.2010.232.235
Hellrich, C. A., Chan, D. V., & Sabol, P. (2011). Cognitive predictors of life skill intervention
outcomes for adults with mental illness at risk for homelessness. The American Journal of
Occupational Therapy, 65(3), 277-286. doi: 10.5014/ajot.2011.001321
Kurtz, M. M., & Mueser, K. T. (2008). A meta-analysis of controlled research on social skills
training for schizophrenia. Journal of Consulting and Clinical Psychology, 76(3), 491-504.
doi: 10.1037/0022-006X.76.3.491
Leff, H. S., Chow, C. M., Pepin, R., Conley, J., Allen, I. E., & Seaman, C. A. (2009). Does one size
fit all? What we can and can't learn from a meta-analysis of housing models for persons
with mental illness. Psychiatric Services, 60(4), 473-482. doi: 10.1176/appi.ps.60.4.473
Lyman, D. R., Kurtz, M. M., Farkas, M., George, P., Dougherty, R. H., Daniels, A. S., . . .
Delphin-Rittmon, M. E. (2014). Skill building: assessing the evidence. Psychiatr Serv,
65(6), 727-738. doi: 10.1176/appi.ps.201300251
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78
MacCourt, P., Wilson, K. & Tourigny-Rivard, M.-F. (2011). Guidelines for Comprehensive
Mental Health Services for Older Adults in Canada. Calgary, AB: MHCC: Retrieved
from http://www.mentalhealthcommission.ca .
Mueser, K. T., Pratt, S. I., Bartels, S. J., Swain, K., Forester, B., Cather, C., & Feldman, J. (2010).
Randomized trial of social rehabilitation and integrated health care for older people with
severe mental illness. Journal of Consulting and Clinical Psychology, 78(4), 561-573. doi:
10.1037/a0019629
Nelson, G., Hall, G. B., & Forchuk, C. (2003). Current and preferred housing of psychiatric
consumers/survivors. Canadian Journal Of Community Mental Health, 22 (1), 5-19.
Retrieved from http://www.cjcmh.com/
Nelson, G., Aubry, T., & Lafrance, A. (2007). A review of the literature on the effectiveness of
housing and support, assertive community treatment, and intensive case management
interventions for persons with mental illness who have been homeless. American Journal
of Orthopsychiatry, 77(3), 350-361. doi:10.1037/0002-9432.77.3.350
Nelson, G., Sylvestre, J., Aubry, T., George, L., & Trainor, J. (2007). Housing choice and control,
housing quality, and control over professional support as ontributors to the subjective
quality of life and community adaptation of people with severe mental illness.
Administration and Policy in Mental Health and Mental Health Services Research, 34(2), 89100. doi: 10.1007/s10488-006-0083-x
Pilling, S., Bebbington, P., Kuipers, E., Garety, P., Geddes, J., Martindale, B., . . . Morgan, C.
(2002). Psychological treatments in schizophrenia: II. Meta-analyses of randomized
controlled trials of social skills training and cognitive remediation. Psychological
Medicine, 32(05), 783-791. doi: 10.1017/S0033291702005640
Pratt, S. I., Van Citters, A. D., Mueser, K. T., & Bartels, S. J. (2008). Psychosocial rehabilitation in
older adults with serious mental illness: A review of the research literature and
recommendations for development of rehabilitative approaches. American Journal of
Psychiatric Rehabilitation, 11(1), 7-40. doi: 10.1080/15487760701853276
Reddon, J. R., Hoglin, B., & Woodman, M.-A. (2008). Immediate effects of a 16-week life skills
education program on the mental health of adult psychiatric patients. Social Work in
Mental Health, 6(3), 21-40. doi:10.1300/J200v06n03_02
Ries, R. K., Dyck, D. G., Short, R., Srebnik, D., Fisher, A., & Comtois, K. A. (2004). Outcomes of
managing disability benefits among patients with substance dependence and severe
mental illness. Psychiatric Services, 55(4), 445-447. doi:10.1176/appi.ps.55.4.445
Roder, V., Mueller, D. R., Mueser, K. T., & Brenner, H. D. (2006). Integrated Psychological
Therapy (IPT) for schizophrenia: Is it effective? Schizophrenia Bulletin, 32(Suppl. 1), S81S93. doi: 10.1093/schbul/sbl021
Rog, D. J., Marshall, T., Dougherty, R. H., George, P., Daniels, A. S., Ghose, S. S., & DelphinRittmon, M. E. (2014). Permanent supportive housing: assessing the evidence.
Psychiatr Serv, 65(3), 287-294. doi: 10.1176/appi.ps.201300261
Life & Leisure Skills
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79
Rosen, M.I., Carroll, K. M., Stefanovics, E., & Rosenheck, R. A. (2009). A randomized controlled
trial of a money management-based substance use intervention. Psychiatric Services,
60(4), 498-504. doi: 10.1176/appi.ps.60.4.498
Siegel, C. E., Samuels, J., Tang, D.-I., Berg, I., Jones, K., & Hopper, K. (2006). Tenant outcomes in
supported housing and community residences in New York city. Psychiatric Services,
57(7), 982-991. doi:10.1176/appi.ps.57.7.982
Tungpunkom, P., Maayan, N., & Soares-Weiser, K. (2012). Life skills programmes for chronic
mental illnesses. Cochrane Database of Systematic Reviews, (1), doi:
10.1002/14651858.CD000381.pub3
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Peer Support
Initial Reviews
144.
Davidson, L., Chinman, M., Kloos, B., Weingarten, R., Stayner, D., & Tebes, J. K.
(1999). Peer support among individuals with severe mental illness: A review of the
evidence. Clinical Psychology: Science and Practice, 6(2), 165-187. doi:
10.1093/clipsy/6.2.165.
An early review (Davidson, Chinman, Kloos et al., 1999) provides some evidence and a
helpful conceptual framework. It defines 3 types of peer support: naturally occurring,
consumer-run services (e.g. mutual support groups), and peer-providers within
conventional services. Existing studies of mutual support groups suggest that they may
improve symptoms, promote larger social networks, and enhance quality of life. This
research is largely from uncontrolled studies, however, and will need to be evaluated
further using prospective, controlled designs.
Implications: Consumer-run services and the use of consumers as providers promise to
broaden the access of individuals with psychiatric disabilities to peer support
145.
Solomon, P. (2004). Peer support/peer provided services underlying processes,
benefits, and critical ingredients. Psychiatric Rehabilitation Journal, 27(4), 392-401.
doi: 10.2975/27.2004.392.401.
Building on the Davidson et al. (1999) review, a more recent one (Solomon, 2004)
provides more evidence and outlines several elements that appear to be critical to the
effectiveness of peer-provided support. This review reports strong evidence regarding
benefits of inclusion of peers in conventional services, e.g. two trials found equivalent
impact of peer provision and standard provider provision of conventional services (e.g.
using peers as case managers or discharge planners); three similar studies found
superior results in terms of reduced hospitalization or crisis services. The review reports
less strong but promising evidence of peer provided services, including peer-run dropins, self-help groups, and peer-run employment programs. Based on these findings, the
author suggests that the critical elements of peer support include: use of experiential
knowledge; mutual benefit/reciprocity; natural support; primary control by peers
(though may involve professionals); delivered by peers who are effective managers of
mental health and substance use issues, and who are knowledgeable about the mental
health system.
Implications: Peer support in all its forms can provide equivalent or superior care to
traditionally provided services. More evidence is needed to replicate the findings
described in this review.
Peer Support
Page 81
146.
Davidson, L., Chinman, M., Sells, D., & Rowe, M. (2006). Peer support among adults
with serious mental illness: A report from the field. Schizophrenia Bulletin, 32(3), 443450. doi: 10.1093/schbul/sbj043.
A subsequent “report from the field” (Davidson, Chinman, Sells et al., 2006) based on
four RCT’s, again shows few differences between conventional care provided by peer
and non-peer case managers.
Implications: Consumer providers can provide equivalent care to traditional services.
More empirical research is needed to discern the unique “value-add” or critical
ingredients of peer support.
Subsequent Studies and Reviews Looking at Critical Ingredients of Peer
Support
147.
Chinman, M., Preety, G., Dougherty, R.H., Daniels, A.S., Ghose, S.S., Swift, A., and
Delphin-Rittman, M. (2014). Peer Support Services for Individuals With Serious
Mental Illnesses: Assessing the Evidence. Psychiatric Services, 65(4), 429-441.
doi:10.1176/appi.ps.201300244
This review assessed the level of evidence and effectiveness of peer support services
delivered by individuals in recovery to those with serious mental illnesses or cooccurring mental and substance use disorders. They found 20 studies across three
service types: peers added to traditional services, peers in existing clinical roles, and
peers delivering structured curricula, rating the evidence as high, moderate, and finding
the level of evidence for each type of peer support service was moderate. The
effectiveness varied by service type. Across the range of methodological rigor, a majority
of studies of two service types—peers added and peers delivering curricula—showed
some improvement favoring peers. Compared with professional staff, peers were better
able to reduce inpatient use and improve a range of recovery outcomes, although one
study found a negative impact. Effectiveness of peers in existing clinical roles was
mixed.
Implications: Peer support services have demonstrated many notable outcomes,
however more and better evidence is needed.
148.
Tsai, J., & Rosenheck, R. A. (2012). Outcomes of a group intensive peer-support model
of case management for supported housing. Psychiatric Services, 63(12), 1186-1194.
This study evaluated a group intensive peer-support (GIPS) model of case management that
was implemented in a supported-housing program for homeless veterans with a broad
range of mental and physical health issues, including substance use. GIPS uses group-based
support lead by peers and was implemented by the U.S. Department of Housing and Urban
Development–Veterans Affairs Supportive Housing (HUD-VASH) program. The study used
administrative data to compare outcomes pre and post implementation, comparing these
with clients at other HUD-VASH sites. The analysis found that GIPS implementation was
associated with a greater increase in social integration ratings, a greater number of case
manager services, and faster acquisition of housing after program admission compared with
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outcomes at the same site before GIPS implementation and at the other sites before and
after implementation.
Implications: GIPS may be a viable service model of supported housing that represents a
recovery-oriented approach that can be scaled up to address homelessness and improve
commuity integration.
149.
Sells, D., Davidson, L., Jewell, C., Falzer, P., & Rowe, M. (2006). The treatment
relationship in peer-based and regular case management for clients with severe
mental illness. Psychiatric Services, 57(8), 1179-1184. doi: 10.1176/appi.ps.57.8.1179.
An RCT trial examining the “value add” of using consumers as case managers (Sells,
Davidson, Jewell, Falzer, & Rowe, 2006) showed that consumer providers were rated
more highly than non-consumer providers in terms of their ability to communicate
positive regard and show understanding. It also showed that non-engaged participants
were more likely to contact peer providers at the outset of treatment. The findings
strongly suggest that peer providers serve a valued role in quickly forging therapeutic
connections with persons typically considered to be among the most alienated from the
health care service system.
Implications: These findings and others (e.g. Felton et al., (1995)) in relation to the
contribution of peer workers on ICM teams to quality of life outcomes) have contributed
to inclusion of peer specialists within regular case management teams, both ACT and
ICM.
150.
Repper, J., & Carter, T. (2011). A review of the literature on peer support in mental
health services. Journal of Mental Health, 20(4), 392-411. Advance on-line publication.
doi: 10.3109/09638237.2011.583947.
A recent review and analysis (Repper & Carter, 2011) presents evidence Peer Support
Workers (PSWs) can be more successful than professionally qualified staff at promoting
hope and belief in the possibility of recovery. They also appear to be more successful at
facilitating increased self-esteem, self-efficacy and self-management. They also confer
advantages in terms of reduced social inclusion. In addition, employment as a PSW
brings benefits for the PSWs themselves. The literature also presents a number of
common challenges including the need to consider boundary and power issues, both
within the peer relationships and with other professionals, and the stress of the role on
the PSW.
Implications: Peer support workers may confer a “value-add” to traditional services in
terms of promoting hope, social inclusion and recovery. The approach also confers
benefits to the PSW’s themselves. In order to realize these benefits, there are certain
implementation challenges (e.g. boundary issues, power differentials, potential burnout) that must be addressed.
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Evidence on the Ontario Consumer/Survivor Development Initiative
(CSDI), the U.S. COSP Study, and other interventions looking at the using
consumer-operated programs to augment support
151.
Nelson, G., Ochocka, J., Janzen, R., & Trainor, J. (2006). A longitudinal study of
mental health consumer/survivor initiatives: Part 2—A quantitative study of impacts
of participation on new members. Journal of Community Psychology, 34(3), 261-272.
doi: 10.1002/jcop.20098.
152.
Nelson, G., Ochocka, J., Janzen, R., Trainor, J., Goering, P., & Lomotey, J. (2007). A
longitudinal study of mental health consumer/survivor initiatives: Part V–Outcomes
at 3-year follow-up. Journal of Community Psychology, 35(5), 655-665. doi:
10.1002/jcop.20171.
These two papers report on initial and subsequent findings of a longitudinal study on
the impact of Consumer/Survivor Initiatives in Ontario. They compared new, active
participants with non-active participants at two time periods. At 9 months, there was a
significant reduction in utilization of emergency room services for active participants,
but not for non-active participants. At 18 months, the active participants showed
significant improvement in social support and quality of life (daily activities) and a
significant reduction in days of psychiatric hospitalization, whereas the non-active
participants did not show significant changes on these outcomes. Also, active CSI
participants were significantly more likely to maintain their involvement in employment
(paid or volunteer) and/or education over the 18-month follow-up period when
compared with those who were not active in CSIs. At 36 months, the continually active
participants scored significantly higher than those who were never active and those who
had decreased involvement over time on measures of community integration, quality of
life (daily living activities), and instrumental role involvement, and significantly lower
on symptom distress.
Implications: Participating in a consumer/survivor initiative (related to education,
mutual support, and/or system advocacy) confers greater benefits than nonparticipation in terms of service usage, social support, quality of life and participation in
meaningful activities. More research is needed in terms of replicating and discerning
critical ingredients.
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153.
Ochocka, J., Nelson, G., Janzen, R., & Trainor, J. (2006). A longitudinal study of
mental health consumer/survivor initiatives: Part 3—A qualitative study of impacts of
participation on new members. Journal of Community Psychology, 34(3), 273-283. doi:
10.1002/jcop.20099.
A qualitative study on the same initiative (Ochocka, Nelson, Janzen, & Trainor, 2006)
provides the participant perception regarding critical ingredients of consumer/survivor
directed initiatives. The helpful qualities that participants reported were: (1) safe
environments that provide a positive, welcoming place to go; (2) social arenas that
provide opportunities to meet and talk with peers; (3) an alternative worldview that
provides opportunities for members to participate and contribute; and (4) effective
facilitators of community integration that provide opportunities to connect members to
the community at large.
Implications: Consumer/Survivor initiatives appear to achieve their impact on quality
of life, recovery and role functioning by providing a safe environment which provides a
chance for interaction, social inclusion and empowerment.
154.
Rogers, E. S., Teague, G. B., Lichenstein, C., Campbell, J., Lyass, A., Chen, R., &
Banks, S. (2007). Effects of participation in consumer-operated service programs on
both personal and organizationally mediated empowerment: Results of a multisite
study. Journal of Rehabilitation Research & Development, 44(6), 785-800. doi:
10.1682/JRRD.2006.10.0125.
The multi-site U.S. COSP study (Rogers et al., 2007) examined the impact of different
types of consumer-run programs (e.g. drop-ins, advocacy and education oriented
programs) which were offered as an adjunct to traditional services. The study showed
modest improvement in empowerment-related outcomes, which were augmented for
those participants who participated more in COSP programs. This result supports other
findings on the same initiative (Cook, 2005) of significantly increased well-being in
COSP participants who had greater program participation.
Implications: Consumer-Operated Programs offered as a complement to traditional
services can confer benefits in terms of increased well-being and empowerment.
155.
Resnick, S., & Rosenheck, R. (2008). Integrating peer-provided services: A quasiexperimental study of recovery orientation, confidence, and empowerment.
Psychiatric Services, 59(11), 1307- 1314. doi: 10.1176/appi.ps.59.11.1307.
Resnick and Rosenheck (2010) describe a “Vet to Vet” peer education and support
program which was provided as an augment to “standard care” provided by the
Veterans Affairs Administration, and showed an improvement in recovery-related and
clinical outcomes, such as functioning and alcohol abuse.
Implications: This provides additional support that consumer-run alternatives provide
an effective adjunct to traditional services.
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156.
Segal, S., Silverman, C., & Temkin, T. (2010). Self-help and community mental health
agency outcomes: A recovery-focused randomized controlled trial. Psychiatric
Services, 61(9), 905-910. doi: 10.1176/appi.ps.61.9.905.
Segal et al. (2010) compared participants in five sites who received standard care from a
community mental health agency and those who also participated in a consumer-run
drop-in, looking at five recovery-focused outcome measures: personal empowerment,
self-efficacy, social integration, hope, and psychological functioning. The sample with
combined services showed greater improvements in personal empowerment, selfefficacy, and independent social integration. Hopelessness and symptoms dissipated
more quickly and to a greater extent in the combined condition than in the community
mental health agency-only condition.
Implications: Participation in member-run self-help combined with traditional services
produced more positive recovery-focused results than traditional community services
alone. This provides additional evidence that consumer-run approaches are effective
complements to traditional care.
157.
Verhaeghe, M., Bracke, P., & Bruynooghe, K. (2008). Stigmatization and self-esteem of
persons in recovery from mental illness: The role of peer support. International
Journal of Social Psychiatry, 54(3), 206–218. doi: 10.1177/0020764008090422.
Verhaeghe, Bracke, and Bruynooghe (2008) examined the hypothesis that peer-provided
social support would buffer the impacts on quality of life and stigma related to the stress
and stigma associated with mental illness. They found that positive impacts on selfesteem accrued only amongst those participants who did not initially have stigmatizing
experiences or perceptions regarding mental illness.
Implications: Pre-existing stigma can act as a barrier to the benefits of peer support.
Such attitudes should be assessed and addressed when considering offering peer
support.
Other References
158.
Cook, J. A. (2005). “Patient centered” and “consumer directed” mental health services.
Retrieved from http://www.cmhsrp.uic.edu/download/IOMreport.pdf
159.
Felton, C. J., Stastny, P., Shern, D. L., Blanch, A., Donahue, S. A., Knight, E., & Brown,
C. (1995). Consumers as peer specialists on intensive case management teams: Impact
on client outcomes. Psychiatric Services, 46(10), 1037-1044. Retrieved from
http://ps.psychiatryonline.org/journal.aspx?journalid=18
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References – Peer Support
Cook, J. A. (2005). “Patient centered” and “consumer directed” mental health services. Retrieved from
http://www.cmhsrp.uic.edu/download/IOMreport.pdf
Chinman, M., Preety, G., Dougherty, R.H., Daniels, A.S., Ghose, S.S., Swift, A., and DelphinRittman, M. (2014). Peer Support Services for Individuals With Serious Mental
Illnesses: Assessing the Evidence. Psychiatric Services, 65(4), 429-441.
doi:10.1176/appi.ps.201300244
Davidson, L., Chinman, M., Kloos, B., Weingarten, R., Stayner, D., & Tebes, J. K. (1999). Peer
support among individuals with severe mental illness: A review of the evidence. Clinical
Psychology: Science and Practice, 6(2), 165-187. doi: 10.1093/clipsy/6.2.165
Davidson, L., Chinman, M., Sells, D., & Rowe, M. (2006). Peer support among adults with
serious mental illness: A report from the field. Schizophrenia Bulletin, 32(3), 443-450.
doi: 10.1093/schbul/sbj043
Felton, C. J., Stastny, P., Shern, D. L., Blanch, A., Donahue, S. A., Knight, E., & Brown, C. (1995).
Consumers as peer specialists on intensive case management teams: Impact on client
outcomes. Psychiatric Services, 46(10), 1037-1044. Retrieved from
http://ps.psychiatryonline.org/journal.aspx?journalid=18
Nelson, G., Ochocka, J., Janzen, R., & Trainor, J. (2006). A longitudinal study of mental health
consumer/survivor initiatives: Part 2—A quantitative study of impacts of participation
on new members. Journal of Community Psychology, 34(3), 261-272. doi:
10.1002/jcop.20098
Nelson, G., Ochocka, J., Janzen, R., Trainor, J., Goering, P., & Lomotey, J. (2007). A longitudinal
study of mental health consumer/survivor initiatives: Part V–Outcomes at 3-year
follow-up. Journal of Community Psychology, 35(5), 655-665. doi: 10.1002/jcop.20171
Ochocka, J., Nelson, G., Janzen, R., & Trainor, J. (2006). A longitudinal study of mental health
consumer/survivor initiatives: Part 3—A qualitative study of impacts of participation on
new members. Journal of Community Psychology, 34(3), 273-283. doi: 10.1002/jcop.20099
Repper, J., & Carter, T. (2011). A review of the literature on peer support in mental health
services. Journal of Mental Health, 20(4), 392-411. Advance on-line publication. doi:
10.3109/09638237.2011.583947
Resnick, S., & Rosenheck, R. (2008). Integrating peer-provided services: A quasi-experimental
study of recovery orientation, confidence, and empowerment. Psychiatric Services, 59(11),
1307- 1314. doi: 10.1176/appi.ps.59.11.1307
Rogers, E. S., Teague, G. B., Lichenstein, C., Campbell, J., Lyass, A., Chen, R., & Banks, S. (2007).
Effects of participation in consumer-operated service programs on both personal and
organizationally mediated empowerment: Results of a multisite study. Journal of
Rehabilitation Research & Development, 44(6), 785-800. doi: 10.1682/JRRD.2006.10.0125
Peer Support
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Sells, D., Davidson, L., Jewell, C., Falzer, P., & Rowe, M. (2006). The treatment relationship in
peer-based and regular case management for clients with severe mental illness.
Psychiatric Services, 57(8), 1179-1184. doi: 10.1176/appi.ps.57.8.1179
Segal, S., Silverman, C., & Temkin, T. (2010). Self-help and community mental health agency
outcomes: A recovery-focused randomized controlled trial. Psychiatric Services, 61(9),
905-910. doi: 10.1176/appi.ps.61.9.905
Solomon, P. (2004). Peer support/peer provided services underlying processes, benefits, and
critical ingredients. Psychiatric Rehabilitation Journal, 27(4), 392-401. doi:
10.2975/27.2004.392.401
Tsai, J., & Rosenheck, R. A. (2012). Outcomes of a group intensive peer-support model of case
management for supported housing. Psychiatric Services, 63(12), 1186-1194.
Verhaeghe, M., Bracke, P., & Bruynooghe, K. (2008). Stigmatization and self-esteem of persons
in recovery from mental illness: The role of peer support. International Journal of Social
Psychiatry, 54(3), 206–218. doi: 10.1177/0020764008090422
Peer Support
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Family Involvement
160.
Cohen, A. N., Drapalski, A. L., Glynn, S. M., Medoff, D., Fang, L. J., & Dixon, L. B. (2013).
Preferences for family involvement in care among consumers with serious mental
illness. Psychiatric Services, 64(3), 257-258.
This study is the first systematic report on preferences expressed by consumers with
serious mental illness for family involvement. It enrolled 232 participants with serious
mental illness whose family was not regularly involved in their care, despite being in
contact with them. Interviews elicited demographic characteristics, treatment preferences
regarding family involvement, and perceived benefits and barriers to involvement. The
study found that seventy-eight percent of participants wanted family members to be
involved in their care, and many desired involvement through several methods. Despite
wanting involvement, participants were concerned with the impact of involvement on both
themselves and their family member. The participant's degree of perceived benefit of family
involvement significantly predicted the degree of desire for family involvement.
Implications: The extent of overall support for family involvement in care underscores the
importance of eliciting consumers’ preferences regarding whether and how to involve their
families, and of actively involving families.
161.
Dixon, L. B., Glynn, S. M., Cohen, A. N., Drapalski, A. L., Medoff, D., Fang, L. J., . . . Gioia, D.
(2014). Outcomes of a brief program, REORDER, to promote consumer recovery and
family involvement in care. Psychiatric Services, 65(1), 116-120.
The Recovery-Oriented Decisions for Relatives’ Support (REORDER) intervention is a
manualized intervention operating on shared decision-making principles. It's aim is to
promote recovery and family involvement in care. This study compared REORDER to
enhanced treatment as usual in a randomized design, amongst 226 veterans with serious
mental illness whose relatives had low rates of involvement. REORDER involved up to three
consumer sessions followed by up to three relative educational sessions if the consumer
and relative consented. Individuals were assessed at baseline and six months later. The
analysis found that eighty-five percent of the 111 randomly assigned REORDER participants
attended at least one REORDER consumer session; of those, 59% had at least one family
session. REORDER participants had significantly reduced paranoid ideation and increased
recovery at follow-up.
Implications: Interventions to promote family involvement can be successfully developed,
which have concrete impacts on recovery.
162.
Mannion, E., Marin, R., Chapman, P., Real, L., Berman, E., Solomon, P., Dinich, D.,
Molinaro, M. & Cantwell, K. (2012). Overcoming systemic barriers to family
inclusion in community psychiatry: The Pennsylvania experience. American Journal
of Psychiatric Rehabilitation, 15 (1), 61-80.
This article describes an initiative to increase family involvement by community
psychiatrists, initiated by the Pennsylvania Psychiatric Leadership Council. The barriers
identified including the need for more flexibility in reimbursing psychiatrists for family
involvement, lack of knowledge of the benefits of involvement, and need for improved
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competencies. Psychiatrists also identified the issue of “family estrangement”, where no
family was available to be involved. Recommendations that were made to increase
involvement included changing payment mechanisms, asking consumers for consent,
reminder phone calls, and creating “family friendly environments”, e.g. by hiring family
peer specialists, and including families on planning and advisory boards.
Implications: Efforts to increase family involvement must target a range of issues,
related to knowledge, skills, funding, and organizational support for family
involvement.
163.
Molinaro, M., Solomon, P., Mannion, E., Cantwell, K. & Evans, A. (2012).
Development and implementation of family involvement standards for behavioral
health provider programs. American Journal of Psychiatric Rehabilitation, 15(1), 81-96.
Link: http://dx.doi.org/10.1080/1547768.2012.655644
An effort was made to create and promote family involvement standards within an
American jurisdiction, but there was limited change in practice patterns.
Implications: Standards may be necessary but they are not sufficient in and of
themselves for increasing family involvement. The authors speculate that standards
must be accompanied by training about the benefits of involvement, as well as by
organizational change.
164.
Mottaghipour, Y. & Bikerton, A. (2005). The Pyramid of Family Care: A framework
for family involvement with adult mental health services. Australian e-Journal for the
Advancement of Mental Health (AeJAMH), 4 (3) ISSN: 1446-7984.
Implications: The pyramid model of family involvement (involvement in assessment,
general information, psychoeducation) is a useful organizational framework for
promoting and evaluating family involvement. For some families, family therapy may
be helpful.
165.
Solomon, P., Molinaro, M., Mannion, E. & Cantwell, K. (2012). Confidentiality
policies and practices in regard to family involvement: Does training make a
difference? American Journal of Psychiatric Rehabilitation, 15 (1), 97-115. Link:
http://dx.doi.org/10.1080/15487768.2012.655648
Despite evidence that involvement of families and significant others improves
rehabilitation outcomes, a significant proportion of service providers may incorrectly
believe that maintaining confidentiality with the client precludes them from
involvement. Approximately 50% of staff surveyed in an American community agency
believed that they were prevented from even listening to families. An intervention to
provide training was evaluated using a pre-post test design, and found that staff often
failed to retain that information. Actual changes in practice were not measured.
Implications: Agencies wishing to increase family involvement must not only provide
information to staff to address misconceptions. They should also seek to understand
and address attitudinal barriers (e.g. that involvement makes their job more difficult)
and structural barriers (e.g. lack of supervision and policies that facilitate involvement)
to family involvement.
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166.
Summerville, C. (2012). Meaningful inclusion and participation of family members in
shared decision making. Schizophrenia Society of Canada.
This paper recommends that professionals seek to involve families in shared decisionmaking. Even if the consumer refuses that involvement, professionals should explore
the reasons for that refusal, and communicate the potential benefits of including the
family. When involvement is not possible, professionals must be aware that
confidentiality does not prevent them from taking information from the family. Families
also require general information about mental illness and about the nature and benefits
of treatment and support. Ideally, they should also be involved in psychoeducation
concerning the specifics of their own loved one.
Implications: Family involvement should be promoted according to the “pyramid”
model (see Mottaghipour and Bikerton, 2005), which at its most basic level entails
involving families in the assessment process (by eliciting information), but also involves
providing general information about mental illness, and more detailed psychoeducation.
Other References
167.
Fraser Health (2011). Families are part of the solution: a strategic direction for family
support and inclusion. Fraser Health Authority Mental Health and Substance Use
Services.
168.
The F.O.R.C.E. (2012). Families matter: a framework for family mental health in
British Columbia. The F.O.R.C.E. Society.
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References – Family Involvement
Cohen, A. N., Drapalski, A. L., Glynn, S. M., Medoff, D., Fang, L. J., & Dixon, L. B. (2013).
Preferences for family involvement in care among consumers with serious mental
illness. Psychiatric Services, 64(3), 257-258.
Dixon, L. B., Glynn, S. M., Cohen, A. N., Drapalski, A. L., Medoff, D., Fang, L. J., . . . Gioia, D.
(2014). Outcomes of a brief program, REORDER, to promote consumer recovery and
family involvement in care. Psychiatric Services, 65(1), 116-120.
Fraser Health (2011). Families are part of the solution: a strategic direction for family support
and inclusion. Fraser Health Authority Mental Health and Substance Use Services.
The F.O.R.C.E. (2012). Families matter: a framework for family mental health in British
Columbia. The F.O.R.C.E. Society.
Mannion, E., Marin, R., Chapman, P., Real, L., Berman, E., Solomon, P., Dinich, D., Molinaro,
M. & Cantwell, K. (2012). Overcoming systemic barriers to family inclusion in
community psychiatry: The Pennsylvania experience. American Journal of Psychiatric
Rehabilitation, 15 (1), 61-80. Link: http://dx.doi.org/10.1080/15487768.2012.655643
Molinaro, M., Solomon, P., Mannion, E., Cantwell, K. & Evans, A. (2012). Development and
implementation of family involvement standards for behavioral health provider
programs. American Journal of Psychiatric Rehabilitation, 15(1), 81-96. Link:
http://dx.doi.org/10.1080/1547768.2012.655644
Mottaghipour, Y. & Bikerton, A. (2005). The Pyramid of Family Care: A framework for family
involvement with adult mental health services. Australian e-Journal for the Advancement of
Mental Health (AeJAMH), 4 (3) ISSN: 1446-7984.
Solomon, P., Molinaro, M., Mannion, E. & Cantwell, K. (2012). Confidentiality policies and
practices in regard to family involvement: Does training make a difference? American
Journal of Psychiatric Rehabilitation, 15 (1), 97-115. Link:
http://dx.doi.org/10.1080/15487768.2012.655648
Summerville, C. (2012). Meaningful inclusion and participation of family members in shared
decision making. Schizophrenia Society of Canada.
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