Treatments have been developed and tested to successfully reduce the symptoms and disabilities of many mental illnesses. Unfortunately, people distressed by these illnesses often do not seek out services or choose to fully engage in them. One factor that impedes care seeking and undermines the service system is mental illness stigma. In this article, we review the complex elements of stigma in order to understand its impact on participating in care. We then summarize public policy considerations in seeking to tackle stigma in order to improve treatment engagement. Stigma is a complex construct that includes public, self, and structural components. It directly affects people with mental illness, as well as their support system, provider network, and community resources. The effects of stigma are moderated by knowledge of mental illness and cultural relevance. Understanding stigma is central to reducing its negative impact on care seeking and treatment engagement. Separate strategies have evolved for counteracting the effects of public, self, and structural stigma. Programs for mental health providers may be especially fruitful for promoting care engagement. Mental health literacy, cultural competence, and family engagement campaigns also mitigate stigma's adverse impact on care seeking. Policy change is essential to overcome the structural stigma that undermines government agendas meant to promote mental health care. Implications for expanding the research program on the connection between stigma and care seeking are discussed.

The Impact of Mental Illness Stigma on Seeking and Participating in Mental Health Care

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

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

Fidelity may be defined as the extent to which delivery of an intervention adheres to the protocol or program model originally developed. Fidelity measurement has increasing significance for evaluation, treatment effectiveness research, and service administration. Yet few published studies using fidelity criteria provide details on the construction of a valid fidelity index. The purpose of this review article is to outline steps in the development, measurement, and validation of fidelity criteria, providing examples from health and education literatures. We further identify important issues in conducting each step. Finally, we raise questions about the dynamic nature of fidelity criteria, appropriate validation and statistical analysis methods, the inclusion of structure and process criteria in fidelity assessment, and the role of program theory in deciding on the balance between adaptation versus exact replication of model programs. Further attention to the use and refinement of fidelity criteria is important to evaluation practice.

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Fidelity Criteria: Development, Measurement, and Validation.

Schizophrenia has traditionally been viewed as a chronic condition with a very pessimistic outlook, but that assumption may not be valid. There has been a growing consumer movement among people with schizophrenia that has challenged both the traditional perspective on the course of illness and the associated assumptions about the possibility of people with the illness living a productive and satisfying life. This new conception of the illness is supported by long-term studies that suggest that as much as 50% of people with the illness have good outcomes. There has also been a change in political and public health perspectives of the illness, stimulated in part by the President's New Freedom Commission on Mental Health. The purpose of this article is to provide an overview of some key themes about the recovery concept, as applied to schizophrenia. The article will address 3 questions: (1) What is recovery? (2) Is recovery possible? and (3) What are the implications of a recovery model for a scientific approach to treatment (ie, the use of evidence-based practices)? Scientific and consumer models of recovery are described, and commonalities and differences are discussed. Priorities for future research are suggested.

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Scientific and Consumer Models of Recovery in Schizophrenia: Concordance, Contrasts, and Implications

Schizophrenia is often conceptualized by clinicians and researchers alike as a chronic illness with persisting, relapsing or deteriorating symptoms, and no hope for sustained remission and recovery of functioning. Countering this perspective, retrospective and prospective studies with both chronic and recent onset patients suggest that schizophrenia has a heterogeneous course, which can be favorably influenced by comprehensive and continuous treatment as well as personal factors such as family support and good neurocognitive functioning. The factors influencing recovery are mostly malleable through treatment and may often lead to a sustained remission of symptoms and normal or near-normal levels of functioning.To facilitate future research in this area, an operational definition of recovery from schizophrenia is proposed that includes symptom remission; full- or part-time involvement in work or school; independent living without supervision by family or surrogate caregivers; not fully dependent on financi...

Operational criteria and factors related to recovery from schizophrenia

Consumer advocacy has emerged as an important factor in mental health policy during the past few decades. Winning consumer support for evidence-based practices requires recognition that consumers' desires and needs for various types of treatments and services differ significantly. The authors suggest that the degree of support for evidence-based practices by consumer advocates depends largely on the degree of disability of the persons for whom they are advocating. Advocates such as members of the National Alliance for the Mentally Ill, who focus on the needs of the most seriously disabled consumers, are most likely to be highly supportive of research that is grounded in evidence-based practices. On the other hand, advocates who focus more on the needs of consumers who are further along their road to recovery are more likely to be attracted to the recovery model. Garnering the support of this latter group entails ensuring that consumers, as they recover, are given increasing autonomy and greater input about the types of treatments and services they receive. The authors suggest ways to integrate evidence-based practices with the recovery model and then suggest a hybrid theory that maximizes the virtues and minimizes the weaknesses of each model.

http://static1.1.sqspcdn.com/static/f/1072889/16305004/1327883371977/evidence+based+meds+NAMI+frese2001.pdf?token=we8U29g%2Bd2cpiEJIaDfuV5KvHNc%3D

Integrating evidence-based practices and the recovery model.

RICHARD FUMERTON [*] KEN KRESS [**] I INTRODUCTION Richard Wright's attempt to distinguish actual causation from proximate causation, and to analyze actual causation--particularly in tort law--has been the most successful and influential work in this area in recent years. [1] Indeed, most scholars think that Wright's analysis of cause as a necessary element in a set of conditions ("NESS") sufficient for an effect [2] is an improvement upon H.L.A. Hart and Tony Honore's classic discussion. [3] In the decade and a half since Wright put forth his theory of causation, there have been a number of attempts to criticize him, but none has undermined the central thrust of his theory. [4] While Wright's view has received deserved praise, his analysis of a NESS requires clarification. Once clarified, however, it is vulnerable to certain fundamental objections. Wright's stated aim is to capture a nonnormative concept of causation. Therefore, this article begins by briefly describing the normative/nonnormative distinction, and how one might invoke this distinction to locate a nonnormative dimension of actual causation (as opposed to proximate causation). After briefly introducing Wright's concept of a NESS for an effect (the concept in terms of which he wants to understand actual causation), the article notes ambiguities in the critical concepts of necessity and sufficiency that he deploys. The article distinguishes a number of different modal concepts and suggests the most plausible interpretation of Wright's use of these concepts. With a more precise understanding of Wright's view in hand, we turn to the question of whether his analysis more effectively handles difficult cases of causation--including multiple causes, preemption, omissions and the like--than does the nearly universal "but for" test deployed by courts as a test of actual causation. While Wright's test has certain advantages over the "but for" test, the article argues that it faces difficult problems of its own. First, it is not clear that Wright can accommodate indeterministic causation. Nor, contrary to what he claims, can his account adequately explain all cases of overdetermination involving preemption. The most obvious revision of Wright's theory to handle cases of preemption (replacing a concept of lawful sufficiency with one of causal sufficiency--a revision with which Wright has indicated sympathy) risks vicious conceptual circularity. It hardly seems likely that one will gain insight into the nature of causation through an account that relies on an understanding of that special kind of sufficiency involved in causation. II CAUSATION AND NORMATIVITY Legal theorists have tried to distinguish nonnormative issues from those that include a normative element. [5] Obvious candidates for nonnormative issues are questions concerning causation. For example, if you are suing me for damages in tort, one of the things you must establish for your suit to be successful is that some action I took caused the relevant damages. [6] This part of your burden seems straightforwardly factual in a way in which, say, your burden of showing that I acted negligently (or tortiously) may not be. It seems plausible on its face to suppose that negligence is a normative notion. When people act negligently, they do not exercise due care. They do not take precautions they ought to take in the face of various possible harms. The italicized terms are paradigm value terms that indicate our subject has taken a normative turn. Before proceeding, it might be worth elaborating on this distinction between nonnormative and normative questions. Some people describe nonnormative issues as factual and normative issues as nonfactual. Many ethical philosophers resist this way of presenting the contrast. These philosophers argue that normative, ethical judgments are factual judgments. Some of these descriptivists are subjectivists, but others would claim that ethical statements make objective assertions. …

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Causation and the Law: Preemption, Lawful Sufficiency, and Causal Sufficiency

This article assesses the criticisms of therapeutic jurisprudence that it cannot resolve value conflicts, especially between autonomy rights and therapeutic values, or, less radically, that it has not provided a general method for resolving conflicts. Grounded in general jurisprudential principles about conflict resolution, including novel developments respecting the meaning of weighing and balancing, the article rejects the criticisms as unfounded. The article also develops and critiques arguments maintaining that therapeutic jurisprudence cannot resolve certain value conflicts because the values are incommensurable. The argument is illustrated by examples concerning the right to refuse treatment, and jurisprudential analyses of that right. Copyright © 1999 John Wiley & Sons, Ltd. Language: en

Therapeutic jurisprudence and the resolution of value conflicts: what we can realistically expect, in practice, from theory.

Coherence and holistic theories of truth maintain that a proposition is true if it fits sufficiently well with other propositions held to be true. Philosophers developed coherence theories in an attempt to avoid inadequacies in foundationalist accounts of truth and justification offered by traditional empiricists. The empiricist program to construct a theory of knowledge that explains all truths as inferences from general first principles and particular experiences has proven to be difficult.1 There are serious objections to all of the major attempts. 2 Led by Professor W.V.O. Quine's powerful arguments,3 coherence and holistic theories of knowledge and justification predominate in current Anglo-American philosophical circles, and foundational empiricist theories are on the wane.4 Coherence theories are more easily charac-

Ken Kress

Papers

Integrating evidence-based practices and the recovery model.

Causation and the Law: Preemption, Lawful Sufficiency, and Causal Sufficiency

Therapeutic jurisprudence and the resolution of value conflicts: what we can realistically expect, in practice, from theory.

Legal Reasoning and Coherence Theories: Dworkin's Rights Thesis, Retroactivity, and the Linear Order of Decisions

Dworkin In Transition