OBJECTIVE:The authors examined consumer outcomes before and after implementing CommonGround, a computer-based shared decision-making program.METHODS:Consumers with severe mental illness (N=167) were interviewed prior to implementation and 12 and 18 months later to assess changes in active treatment involvement, symptoms, and recovery-related attitudes. Providers also rated consumers on level of treatment involvement.RESULTS:Most consumers used CommonGround at least once (67%), but few used the program regularly. Mixed-effects regression analyses showed improvement in self-reported symptoms and recovery attitudes. Self-reported treatment involvement did not change; however, for a subset of consumers with the same providers over time (N=83), the providers rated consumers as more active in treatment.CONCLUSIONS:This study adds to the growing literature on tools to support shared decision making, showing the potential benefits of CommonGround for improving recovery outcomes. More work is needed to better engage consumers in CommonGround and to test the approach with more rigorous methods.

Located in a community mental health center, the first decision support center in psychiatry used peer support and an Internet-based software program, CommonGround, to assist consumers in decisional uncertainty about psychiatric medication use and to foster shared decision making between the consumer and prescriber. This study examined the impact of the decision support center on the consumer-doctor interaction in the medication consultation. A pretest/posttest design assigned consumers to either an experimental or control group for 4 months. The Measure of Patient-Centered Communication (MPCC) (Brown, Stewart, McCracken, McWhinney, & Levenstein, 1986) was used to evaluate the medication consultation. The Patient Perception of Patient-Centeredness Questionnaire (PPPC) (Stewart, Meredith, Ryan, & Brown, 2004) was used to evaluate the consumer's and prescriber's perceptions of the consultation. A one-way multivariate analysis of covariance was not significant for the combined dependent variable of the measures at Time 2, while controlling for the measures at Time 1. When the CommonGround report was referenced in the experimental group, post hoc analyses revealed significant differences (t[ 41] = 4.14, p =.001) in the PPCC-consumer score. This study provides provisional evidence of the effectiveness of a shared decision-making intervention. The clinical potential of a program that assists mental health consumers in communicating decisional uncertainty and developing shared decisions concerning medication use is worthy of further study.

OBJECTIVE:Shared decision making is widely recognized to facilitate effective health care. The purpose of this study was to assess the applicability and usefulness of a scale to measure the presence and extent of shared decision making in clinical decisions in psychiatric practice. METHODS:A coding scheme assessing shared decision making in general medical settings was adapted to mental health settings, and a manual for using the scheme was created. Trained raters used the adapted scale to analyze 170 audio-recordings of medication check-up visits with either psychiatrists or nurse practitioners. The scale assessed the level of shared decision making based on the presence of nine specific elements. Interrater reliability was examined, and the frequency with which elements of shared decision making were observed was documented. The association between visit length and extent of shared decision making was also examined. RESULTS:Interrater reliability among three raters on a subset of 20 recordings ranged from 67% to 100% agreement for the presence of each of the nine elements of shared decision making and 100% for the agreement between provider and consumer on decisions made. Of the 170 sessions, 128 (75%) included a clinical decision. Just over half of the decisions (53%) met minimum criteria for shared decision making. Shared decision making was not related to visit length after the analysis controlled for the complexity of the decision. CONCLUSIONS:The rating scale appears to reliably assess shared decision making in psychiatric practice and could be helpful for future research, training, and implementation efforts.

Supported Education (SEd) is emerging as an evidence-based practice (EBP) effective at helping individuals with psychiatric disabilities increase their educational achievement. Individual Placement and Support (IPS), a specialized form of supported employment (SE) for people with psychiatric disabilities, is an established EBP and has been suggested as an optimal vehicle through which SEd could be delivered. This study attempts to: (1) discover which elements of supported education services are perceived as important by IPS programs and (2) to determine what, if any, educational services are currently being provided within these programs.Respondents rated most highly providing concrete educational services and minimizing educational service barriers for participants. Although still rated highly, there was less importance placed on documenting outcomes or informing others about the educational services being provided by supported employment programs. Approximately 57% of programs were providing some form of educational service and support. The results from this survey provide information about how IPS and SEd are currently being delivered and highlights a need for further research about how SEd and IPS can be optimally delivered together.

Objective: The aim of this preliminary study was to examine the impact of participation in an illness self-management recovery program (Wellness Recovery Action Planning WRAP) on the ability of individuals with severe mental illnesses to achieve key recovery related outcomes. Methods: A total of 30 participants from three mental health centers were followed immediately before and after engaging in a 12-week WRAP program. Results: Three paired sample t-tests were conducted to determine the effectiveness of WRAP on hope, recovery orientation, and level of symptoms. A significant positive time effect was found for hope and recovery orientation. Participants showed improvement in symptoms, but the change was slightly below statistical significance. Conclusions: These preliminary results offer promising evidence that the use of WRAP has a positive effect on self-reported hope and recovery-related attitudes, thereby providing an effective complement to current mental health treatment.

OBJECTIVE This study examined the positive effects on recovery outcomes for people with severe and persistent mental illness using peer-led groups based on Pathways to Recovery: A Strengths Recovery Self-Help Workbook (PTR). PTR translates the evidence-supported practice of the Strengths Model into a self-help approach, allowing users to identify and pursue life goals based on personal and environmental strengths. METHODS A single-group pretest-posttest research design was applied. Forty-seven members in 6 consumer-run organizations in one Midwestern state participated in a PTR peer-led group, completing a baseline survey before the group and again at the completion of the 12-week sessions. The Rosenberg Self-Esteem Scale, the General Self-Efficacy Scale, Multidimensional Scale of Perceived Social Support, the Spirituality Index of Well-Being, and the Modified Colorado Symptom Index were employed as recovery outcomes. Paired Hotelling's T-square test was conducted to examine the mean differences of recovery outcomes between the baseline and the completion of the group. RESULTS Findings revealed statistically significant improvements for PTR participants in self-esteem, self-efficacy, social support, spiritual well-being, and psychiatric symptoms. CONCLUSIONS This initial research is promising for establishing PTR as an important tool for facilitating recovery using a peer-led group format. The provision of peer-led service has been emphasized as critical to integrating consumers' perspectives in recovery-based mental health services. Given the current federal funding stream for peer services, continued research into PTR and other peer-led services becomes more important.

Clubhouses and consumer-run drop-in centers (CRDIs) are two of the most widely implemented models of consumer-centered services for persons with serious mental illness. Differences in structure and goals suggest that they may be useful to different types of consumers. Information on what types of consumers use which programs would be useful in service planning. This study analyzes data from the authors' NIMH-funded research on 31 geographically matched pairs of clubhouses and CRDIs involving more than 1,800 consumers to address the following question: are there significant differences in the characteristics and outcomes of members of clubhouses versus CRDIs? Results from multilevel analyses indicated that clubhouse members were more likely to be female, to receive SSI/SSDI, to report having a diagnosis of schizophrenia, and to live in dependent care; and they reported both a greater number of lifetime hospitalizations and current receipt of higher intensity traditional MH services. Controlling for differences in demographic characteristics, psychiatric history, and mental health service receipt, clubhouse members also reported higher quality of life and were more likely to report being in recovery. CRDI consumers were more likely to have substance abuse histories. Possible reasons for the differences are discussed. The results suggest that CRDIs are a viable alternative to more traditional mental health services for individuals who might not otherwise receive mental health services.

This study reports on a qualitative study of barriers to EBP implementation in one state that sought to implement supported employment and integrated dual diagnosis treatment. The study found that the most significant obstacles emanated from the behavior of supervisors, front-line staff and other professionals in the agency. A lack of synergy profoundly impeded implementation.

This column presents preliminary findings of an intervention to support shared decision making in psychopharmacology consultation. The waiting area in an urban psychiatric medication clinic was transformed into a peer-run Decision Support Center featuring a user-friendly, Internet-based software program with which clients could create a one-page computer-generated report for use in the medication consultation. The Decision Support Center was used 662 times by 189 unique users from a young-adult and general adult case management team from October 2006 to September 2007. All clients had severe mental disorders. Only ten clients refused to use the intervention at some point during the pilot study. Focus groups with medical staff (N=4), clients (N=16), case managers (N=14), and peer-specialist staff (N=3) reported that the intervention helped to create efficiencies in the consultation and empower clients to become more involved in treatment-related decision making. A randomized controlled trial is currently in process.

The purpose of this study was to explore potential racial differences in the experience of support offered by consumer-centered services for adults with serious mental illness. The study used hierarchical linear modeling to examine the level of support consumers report receiving from programs and the extent to which program-level characteristics reflecting racial diversity differentially influence white and African American consumers. The study used data from interviews with 1,072 white and African American consumers throughout Michigan and from selected program-level data. African Americans reported that a smaller proportion of their network comes from their program, although this is not related to program-level characteristics. Interaction effects suggest that the proportion of consumers in a program who are African American differentially influences the sense of community reported by white and African Americans. Implications for understanding racial dynamics within consumer-centered services are provided.

Spirituality has been cited in the literature as having a positive effect on mental health outcomes. This paper explores the relationship of spirituality to demographic, psychiatric illness history and psychological constructs for people with mental illness (N=1835) involved in consumer-centered services (CCS-Clubhouses and Consumer run drop-in centers). Descriptive statistics indicate that spirituality is important for at least two thirds of the members in the study. Members primarily indicated participation in public spiritual activities (i.e., church, bible study groups), followed by private activities (prayer, reading the bible, and meditation) (both of which were centered on belief in the transcendent). A logistic regression analysis was done to explore variables related to spirituality (i.e., demographics, psychiatric illness history, and psychological constructs). Results suggest that age, gender, having psychotic symptoms, having depressive symptoms, and having a higher global quality of life, hope and sense of community were all significant correlates of spirituality.

This study evaluated a one-day domestic violence training for Temporary Assistance for Needy Families (TANF) workers and analyzed the relationship between worker characteristics and the use of work exemptions. In a post-only evaluation, trained workers reported a greater tendency than untrained workers to refer clients to couples counseling, make a safety plan, and file a report to child protection services. In a pre/post evaluation, workers reported after training that they would be less likely to refer clients to couples counseling, and more likely to ask about the emotional and physical impact of abuse, make a safety plan, and ask about access to weapons. Workers most likely to offer a waiver from work requirements reported a higher likelihood of making referrals for a variety of services.

This study used a mixed methods approach to describe and analyze data from groups observed in two types of mental health consumer-centered programs, namely consumer-run drop-in centers and clubhouses. An overview of consumer-centered programs is presented, followed by a report of the study which includes a description of the groups in the sample and data on the effects of group process and group leader characteristics on group functioning. Results indicate that, for the most part, the groups were task oriented (e.g., planning events or discussing issues about the center). Psychoeducation and recovery were also frequent topics in the group meetings. In terms of group participation, consumers took on various assignments, served as facilitators, assumed tasks and roles, shared experiences, and provided support to other group participants. A major finding is that group leaders displayed both good and poor leadership behaviors. The good leadership behaviors were often efforts to respond to problematic responses of members and poor leadership behaviors often elicited such responses. The qualitative analysis provided examples of how these behaviors affected the group sessions. This pilot study, by identifying some of the group conditions present in such groups, should lead to new studies that are based on specific hypotheses concerning the relationships that exist among group conditions, interventions to improve such conditions, and outcomes for participants.

With the emphasis on the use of evidence-based practices has come a need to measure the fidelity of replications to the operations and principles of original models. Recent reviews have focused on methods to develop fidelity measures for evidence-based program models. However, the issue of how to validate such measures has been given scant attention. The research reported here attempted to validate a fidelity rating instrument (FRI) for consumer-operated drop-in centers on the basis of convergent validation methods. That is, fidelity ratings by trained observers were validated in relation to reports about similar concepts from the users of the centers. The authors describe their methods and present results indicating that all but 4 of 14 fidelity variables from the FRI were validated, as hypothesized. The authors discuss the success of this approach as well as its limitations and identify issues in the further development of fidelity measures.

Attention to psychosocial rehabilitation (PSR) practice has expanded in recent years. However, social work research studies on PSR are not numerous. This study focuses on operational characteristics of clubhouses, a major PSR program model, and the organizational attributes (including resource levels) that predict the extent to which the clubhouse constitutes an empowering setting. The authors present data from a statewide sample of 30 clubhouses, annually serving nearly 4,000 consumers (adults with serious mental illnesses), based on interviews of clubhouse directors, on-site observations, and government information sources. Results indicate that users were predominantly male, white, and middle age; about one-third had a major functional disability. There were wide variations in member characteristics as well as in resource levels. In terms of empowerment, this sample of clubs averaged rather low levels of member involvement in governance and operations but seemed to provide members with opportunities and assistance in making their own decisions. The empowerment variables had different predictors, including client characteristics, urban-related characteristics, staffing, and resource levels. Implications for social work practice in PSR settings are discussed.

In-depth phone surveys were conducted with 32 consumer-run drop-in centers in Michigan. Results indicate that centers serve a diverse array of consumers at an average cost of about dollar 8 daily per person. Funding levels, salaries, and services are quite heterogeneous among centers. Those with higher funding levels, greater involvement with other human service agencies, and higher overall CMH county budgets differed significantly in total services and activities provided than those centers with less of each of these resources. Daily attendance was predicted by other-agency involvement, participation of volunteer personnel, and negative neighborhood context.

This paper briefly reviews the recent history of psychosocial treatment for adults with severe mental illnesses in the United States. It examines the current sources and financing of such care, revealing the planned and unplanned reclassification of entitled beneficiaries and eligible patients, appropriate treatment, acceptable outcomes, and levels and sources of payment. One illustration of this phenomenon is seen in current efforts to identify and deliver only those public services that are covered by Medicaid, so as to allocate state resources only when they can be matched by federal monies. Another is the reliance on private health insurance, tied in the U.S. almost exclusively to employment, for medical care delivered under an acute, rather than a chronic care model. These analyses conclude with a discussion of the implicit and explicit mechanisms used to ration access to psychosocial treatment in the United States. The implications for individuals with serious mental illnesses, their families, and the general public are placed in historical and current policy contexts, recognizing the economic, social, and clinical variables that can moderate outcomes.