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Journal ArticleDOI

A 2-year follow-up study of people with severe mental illness involved in psychosocial rehabilitation

15 Jul 2014-Nordic Journal of Psychiatry (Informa Healthcare)-Vol. 68, Iss: 6, pp 401-408
TL;DR: The results indicate that the BPR approach has impact on clients’ health, empowerment, quality of life and in particular concerning psychosocial functioning.
Abstract: Backgrounds. A focus on psychiatric rehabilitation in order to support recovery among persons with severe mental illness (SMI) has been given great attention in research and mental health policy, b ...

Summary (3 min read)

A two-year follow-up study of people with severe mental illness involved in psychosocial rehabilitation

  • Svedberg, Petra, Associate professor 1., Svensson, Bengt, Associate professor 2., Hansson, Lars, Professor 2., Jormfeldt, Henrika, Associate professor 1.
  • School of Social and Health Sciences, Halmstad University, Sweden 2. Department of Health Sciences, Lund University, Sweden Corresponding author: Petra Svedberg School of Social and Health Sciences Halmstad University SE - 301 18 Halmstad Sweden Phone: +46-35167786 Fax: +46-35167264 Email: petra.svedberg@hh.se 2.

Backgrounds

  • A focus on psychiatric rehabilitation in order to support recovery among persons with severe mental illness (SMI) has been given great attention in research and mental health policy, but less impact on clinical practice.
  • There is a lack of research regarding the model called “Psychiatric Rehabilitation Approach from Boston University (BPR)”.
  • The aim was to investigate the outcome of the BPR intervention regarding changes in life situation, use of health care services, quality of life, health, psychosocial functioning and empowerment.
  • In total 71 clients completed the assessment at baseline and of these 49 completed the 2-year follow-up assessments.
  • Furthermore, 65% of the clients reported that they had mainly or almost completely achieved their self-formulated rehabilitation goals at the 2-year follow-up.

Background

  • A focus on psychiatric rehabilitation in order to support recovery among persons with severe mental illness (SMI) has been given great attention in research and mental health policy, but still lacks implementation in clinical practice in a broader perspective [1] [2].
  • Common elements of these programs are that they offer extensive and person-centred support aimed at strengthening the person’s ability to take responsibility for their lives and thereby improve their quality of life [6].
  • The BPR model has been investigated in some empirical studies from United States [18] [19] and in a few studies from European countries [20-23].
  • Swildens et al [22] showed that the BPR was effective in supporting persons with SMI in societal participation and to achieve self-formulated goals, but no effects were found regarding social functioning, needs for care, and quality of life.
  • This study was conducted as a part of an implementation project in the county of Halland that aimed to develop mental health rehabilitation services and to initiate a recovery-oriented approach for persons with severe mental illness.

Aims

  • The aims of the present study were to investigate outcome of the intervention in terms of changes in life situation, use of health care services, quality of life, health, psychosocial functioning and empowerment.
  • A further aim was to investigate to what extent the clients’ self-formulated rehabilitation goals were attained.

Design

  • The study has a prospective longitudinal design and the data collection at baseline started in August 2007 and a 2-year follow-up data collection ended in December 2010.
  • At both baseline and follow-up all clients were interviewed by either of two of the authors (PS or HJ).
  • The interviewers had no involvement in the clients’ care or rehabilitation.

Settings and participants

  • The setting was seven mental health services who implemented the BPR approach in the county of Halland in Sweden.
  • Six of these were municipal services for persons with mental illness and one was an outpatient specialist psychiatric service.
  • Two of the six municipal services only provided vocational rehabilitation.
  • A total of 71 clients consented to participate and completed the assessment at baseline, and of these 49 completed the 2-year follow-up data collection.

Intervention

  • The BPR approach is based on the principles and practices of psychiatric rehabilitation developed by Anthony, Cohen and Farkas [24] at Boston University.
  • The model was first applied in vocational rehabilitation, and then extended to educational and housing situations [17].
  • The model is highly individualized and is based entirely on the individual’s unique needs and preferences.
  • The purpose of the BPR intervention in Halland was to support and guide the client to formulate and achieve his/her own goals for various life areas such as work/occupation, 7     housing, education and leisure time.
  • A program fidelity evaluation was carried out using a new instrument developed by the research group inspired by a Dutch questionnaire [25].

Outcome measures

  • Subjective quality of life was assessed by the Manchester Short Assessment of Quality of Life scale.
  • The instrument contains 16 items including satisfaction with work, finances, social relations, leisure, living situation, safety, family relations, sexual relations, and health using a 7-point scale ranging from could not be worse to could not be better.
  • Needs of care were measured using the Camberwell Assessment of Needs Short Appraisal Schedule, [29].
  • This is a 22-item self-report questionnaire with three subscales: autonomy, social involvement and comprehensibility.
  • The instrument has showed good reliability and validity in a Swedish context [33- 35].

Ethics

  • The study was approved by the Regional Ethical Review Board for southern Sweden, Dnr 316/2007.
  • All participants were informed both orally and in writing about the purpose and the structure of the study before they gave their informed consent.
  • Participation was voluntary, and the participants were informed about the ethical considerations of confidentiality and that they could withdraw from the study at any time.

Statistical analysis

  • Differences between baseline and 2-year follow-up were analyzed with Student’s t-test.
  • Analyses of differences between subcategories of clients were made using the χ2 test.
  • The statistical software used was SPSS version 15.

Socio-demographic characteristics

  • The mean years since first admission were 8 years (range 0-24).
  • A majority (57 %) of the participants were single, 30.6 % were married or co-habiting and 98% had an independent living.
  • The patients who did not participate in the follow-up were not different in any of the sociodemographic variables measured at baseline compared with the patients who completed the study (See table 1).

External life situation

  • The clients’ external life situation in terms of housing, education and leisure activities showed no significant differences between baseline and the two-year follow-up.
  • Quality of life, health, empowerment and psychosocial functioning Quality of life, health, empowerment as well as psychosocial functioning were significantly improved between baseline and the two year follow up (table 2).
  • Effect sizes for all these domains were generally small, with the exception of psychosocial functioning where the effect size was large.
  • Thirty-two of the clients (65%) considered that they mainly or almost completely had achieved their goals.

Discussion

  • The most significant finding of the present study was an improved psychosocial functioning (large effect size) at the two-year follow-up.
  • Health, empowerment, quality of life and psychosocial functioning improved over time, with large significant differences between clients who mainly/completely achieved their self-formulated rehabilitation goals and the clients who only to a small extent or not at all achieved their goals.
  • In the study by Rogers, Anthony and Farkas [17] there were no significant differences between the intervention group and the control group regarding work situation at a two-year follow up.
  • There is a risk regarding self-reported data that the client under-estimate their symptoms and dysfunction as well as diagnosis.
  • In spite of these limitations the authors still suggest that the BPR approach can be an important factor in improving clients’ clinical and social situation.

Conclusion

  • In conclusion this study provides support for that BPR contribute to an improved life situation in terms of employment and sheltered employment/job training, and a decrease in number of people with disability pension, while no changes were shown concerning housing situation, education and leisure time.
  • This study also provides support for that BPR contribute to an increased quality of life, health, empowerment and psychosocial functioning as well as to a reduced utilization of psychiatric services.

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LUND UNIVERSITY
PO Box 117
221 00 Lund
+46 46-222 00 00
A 2-year follow-up study of people with severe mental illness involved in psychosocial
rehabilitation
Svedberg, Petra; Svensson, Bengt; Hansson, Lars; Jormfeldt, Henrika
Published in:
Nordic Journal of Psychiatry
DOI:
10.3109/08039488.2013.851737
2014
Link to publication
Citation for published version (APA):
Svedberg, P., Svensson, B., Hansson, L., & Jormfeldt, H. (2014). A 2-year follow-up study of people with severe
mental illness involved in psychosocial rehabilitation.
Nordic Journal of Psychiatry
,
68
(6), 401-408.
https://doi.org/10.3109/08039488.2013.851737
Total number of authors:
4
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A two-year follow-up study of people with severe mental illness involved in psychosocial
rehabilitation
Svedberg, Petra, Associate professor
1
., Svensson, Bengt, Associate professor
2
., Hansson,
Lars, Professor
2
., Jormfeldt, Henrika, Associate professor
1
.
1. School of Social and Health Sciences, Halmstad University, Sweden
2. Department of Health Sciences, Lund University, Sweden
Corresponding author:
Petra Svedberg
School of Social and Health Sciences
Halmstad University
SE - 301 18 Halmstad
Sweden
Phone: +46-35167786
Fax: +46-35167264
Email: petra.svedberg@hh.se

2"
"
Abstract
Backgrounds
A focus on psychiatric rehabilitation in order to support recovery among persons with severe
mental illness (SMI) has been given great attention in research and mental health policy, but
less impact on clinical practice. Despite the potential impact of psychiatric rehabilitation on
health and wellbeing, there is a lack of research regarding the model called “Psychiatric
Rehabilitation Approach from Boston University (BPR)”.
Aim: The aim was to investigate the outcome of the BPR intervention regarding changes in
life situation, use of health care services, quality of life, health, psychosocial functioning and
empowerment.
Methods: The study has a prospective longitudinal design and the setting was seven mental
health services who worked with the BPR in the county of Halland in Sweden. In total 71
clients completed the assessment at baseline and of these 49 completed the 2-year follow-up
assessments.
Results: The most significant finding was an improved psychosocial functioning at the
follow-up assessment. Furthermore, 65% of the clients reported that they had mainly or
almost completely achieved their self-formulated rehabilitation goals at the 2-year follow-up.
There were significant differences with regard to health, empowerment, quality of life and
psychosocial functioning for those who reported that they had mainly/completely had
achieved their self-formulated rehabilitation goals compared to those who reported that they
only had to a small extent or not at all reached their goals.

3"
"
Conclusions: Our results indicate that the BPR approach has impact on clients’ health,
empowerment, quality of life and in particular concerning psychosocial functioning.
Key words: psychiatric rehabilitation, psychosocial rehabilitation, severe mental illness,
Choose–Get–Keep Model, Boston psychiatric rehabilitation approach

4"
"
Background
A focus on psychiatric rehabilitation in order to support recovery among persons with severe
mental illness (SMI) has been given great attention in research and mental health policy, but
still lacks implementation in clinical practice in a broader perspective [1] [2]. The
development of mental health systems in Sweden have in recent decades been characterized
by a shift from traditionally hospital-based care to community-based care [3]. However,
moving toward a recovery-oriented approach takes time and presents several challenges for
mental health services [4]. With the increasing emphasis on an evidence-based practice and
research findings which confirm that people with SMI can recover from their illness [5] there
is a promising future for a further focus on recovery-oriented mental health care services [2].
!
The development of new models for psychiatric rehabilitation have resulted in a number of
intervention programs designed to improve health, social functioning and the quality of life of
persons with SMI. Common elements of these programs are that they offer extensive and
person-centred support aimed at strengthening the person’s ability to take responsibility for
their lives and thereby improve their quality of life [6]. Most programs include interventions
aimed to improve social skills, to create opportunities for independent living, to get persons
into work and actions to achieve a meaningful leisure time. The most common rehabilitation
oriented models are the Fountain House model of psychiatric rehabilitation [7], case-
management [8] [9], assertive community treatment (ACT) [10] [11] [2] and supported
employment (SE) [12]. Both ACT [13] [14] and supported employment according to the IPS
model [12] [15] have been identified as evidence-based practices that support people with
severe mental illness. Despite the potential impact of psychiatric rehabilitation on wellbeing
and health, there is a lack of research regarding the model called Psychiatric Rehabilitation
Approach from Boston University (BPR)
1
[16] [17] although it is established in clinical
practice in a number of countries. The BPR model has been investigated in some empirical
studies from United States [18] [19] and in a few studies from European countries [20-23].
Four of these studies used a randomized controlled design [18] [19] [22] [23]. Swildens et al
[22] showed that the BPR was effective in supporting persons with SMI in societal
participation and to achieve self-formulated goals, but no effects were found regarding social
functioning, needs for care, and quality of life. Rogers, Anthony, Lyss and Penk [18] found no
significant differences between the intervention group and a control group regarding
"""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""
1
"Sometimes "called"ChooseGetKeep Model (CGK)"

Citations
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BookDOI
01 Jan 2016
TL;DR: This chapter discusses the person as center of health, the experience of and values in health, and the interdisciplinary team approach for clinical care.
Abstract: Introduction -- The person as center of health -- Person-centered patient perspectives -- Person-centered family perspectives -- Health status from illness to wellbeing -- Contributory factors to health and illness -- The experience of and values in health -- Joint diagnostic understanding: Interviewing and assessment -- Shared decision-making between clinicians, patients and families -- Interdisciplinary team approach for clinical care -- Person-centered prevention -- Person-centered rehabilitation -- Person-centered health promotion -- Person-centered care for major mental disorders -- Person-centered care for psychiatric and general medical comorbidity -- Person-centered forensic psychiatry -- People-centered organization of psychiatric services -- Person-centered public mental health -- Person-centered psychiatric education -- Person-centered psychiatric and mental health research -- Epilogue.

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Cites background from "A 2-year follow-up study of people ..."

  • ...However, as a clinical discipline, psychiatry must integrate phenomenological aspects of experience with naturalistic explanations of mental mechanisms [60, 63, 72]....

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  • ...Ornish has found in longitudinal studies that they lead to improved well-being, including longer telomeres (a predictor of longevity) compared to others who do not change their lifestyle [53, 54, 60]....

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  • ...Concern about the risk of appropriating the other’s cultural knowledge, and reducing culture to a set of impersonal “factors” led medical educators to the construct of cultural humility as corrective stance [60]....

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  • ...Their points of convergence encompass a holistic theoretical perspective, an emphasis on contextualization and establishing a common ground for understanding and action, development of person-centered procedures for clinical care and health promotion, and, last but not least, an ethical commitment [60]....

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  • ...However, these factors interact between themselves and many are mediators for the development of health problems as is the case with certain biological factors [60], like the genetic stock of the individual (through epigenetics)....

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TL;DR: Whether mental well-being has prognostic significance or other utility in this context is discussed, as well as how to measure it.
Abstract: Mental well-being is being used as an outcome measure in mental health services The recent Chief Medical Officer's (CMO's) report raised questions about mental well-being in people with mental illness, including how to measure it We discuss whether mental well-being has prognostic significance or other utility in this context

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Journal ArticleDOI
TL;DR: It is proposed that recovery-oriented services should seek to enhance goal setting and goal-pursuit, and to train practitioners in these areas, to support personal recovery and other favorable rehabilitation outcomes.
Abstract: Personal goals/plans play a central role in personal recovery and psychiatric rehabilitation of persons with mental illnesses. Yet, few studies have explored whether perceiving practitioners' assistance towards the pursuit of goals are associated with personal recovery and other favorable rehabilitation outcomes. A total of 2121 mental health consumers, of which 1222 use supported-housing services and 899 use group-home services, completed self-report questionnaires as part of a larger quality-assurance study conducted during the years 2013–2014. Eighty percent of participants living in supported-housing and 72% living in group-homes reported having personal goals/plans for the forthcoming year. Furthermore, their type of goals was different. Irrespective of the type of goal or housing service, participants who reported having goals/plans (compared with those who did not) showed higher levels of personal recovery and more favorable psychosocial outcomes. Regression analyses showed that perceiving professional staff members (but not para-professionals) as assisting in pursuing goals/plans was positively associated with personal recovery. This study empirically validates the value of having personal goals and professionals' assistance in pursuing goals/plans in regards to personal recovery. We propose that recovery-oriented services should seek to enhance goal setting and goal-pursuit, and to train practitioners in these areas.

15 citations

Journal ArticleDOI
TL;DR: A qualitative content analysis of 10 transcribed semistructured individual interviews was used to describe and explore clients’ experiences of the BPR during an implementation project in Sweden, showing that clients do not always recognize nor are able to verbalize their goals before they have been given the possibility to reflect their thoughts in collaboration with a trusted person.
Abstract: The Boston Psychiatric Rehabilitation Approach (BPR) is person-centered and characterized by being based entirely on the individual's unique needs and preferences in the areas of working, learning, social contacts, and living environment. Nevertheless, the person-centered approach is lacking firm evidence regarding outcomes, and empirical studies regarding clients' experiences of this particular model are needed. A qualitative content analysis of 10 transcribed semistructured individual interviews was used to describe and explore clients' experiences of the BPR during an implementation project in Sweden. The findings from the interviews could be summarized in "A sense of being in communion with self and others" theme, consisting of three categories: increased self-understanding, getting new perspectives, and being in a trusting relationship. The results showed that clients do not always recognize nor are able to verbalize their goals before they have been given the possibility to reflect their thoughts in collaboration with a trusted person. The guidelines of the approach are intended to support the clients' ability to participate in decision making regarding their own care. More research about efficacy of different rehabilitation approaches and exploration of fidelity to guidelines of rehabilitation programs are required.

12 citations


Cites background from "A 2-year follow-up study of people ..."

  • ...Ten participants were purposefully selected from the group of 49 clients who had completed the 2-year follow-up evaluation project (Svedberg et al., 2013) to attain variation in terms of sex, age, and experiences regarding duration of illness and previous contacts with mental health services....

    [...]

Journal ArticleDOI
TL;DR: Findings suggest that it is important to discuss clients' wishes and ambitions and form an agreement on goals to attain successful rehabilitation outcomes, which underscores the importance of investing in these forms of client support.
Abstract: Objective:A key aspect of psychiatric rehabilitation is supporting individuals with serious mental illness in reaching personal goals. This study aimed to investigate whether various aspects of the...

9 citations

References
More filters
Journal ArticleDOI
TL;DR: It is suggested that PR is effective in supporting patients with SMI to reach self-formulated rehabilitation goals and in enhancing societal participation, although no effects were found on the measures of functioning, need for care, and quality of life.
Abstract: Objective: To investigate the effect of the Boston Psychiatric Rehabilitation (PR) Approach on attainment of personal rehabilitation goals, social functioning, empowerment, needs for care, and quality of life in people with severe mental illness (SMI) in the Netherlands. Method: A 24-month, multicentre, randomized controlled trial was used to compare the results of PR to care as usual (CAU). Patients with SMI were randomly assigned by a central randomization centre to PR (n = 80) or CAU (n = 76). The primary outcome of goal attainment was assessed by independent raters blind to treatment allocation. Measures for secondary outcomes were change in work situation and independent living, the Personal Empowerment Scale, the Camberwell Assessment of Needs, and the World Health Organization Quality of Life assessment. Effects were tested at 12 and 24 months. Data were analyzed according to intention to treat. Covariates were psychiatric centre, psychopathology, number of care contacts, and educational level of the professionals involved. Results: The rate of goal attainment was substantially higher in PR at 24 months (adjusted risk difference: 21%, 95% CI 4% to 38%; number needed to treat [NNT] = 5). The approach was also more effective in the area of societal participation (PR: 21% adjusted increase, CAU: 0% adjusted increase; NNT = 5) but not in the other secondary outcome measures. Conclusions: The results suggest that PR is effective in supporting patients with SMI to reach self-formulated rehabilitation goals and in enhancing societal participation, although no effects were found on the measures of functioning, need for care, and quality of life.

51 citations

Journal ArticleDOI
TL;DR: Some of the names of these principles that come immediately to mind are such principles as person involvement, growth orientation, hope, self-determination and choice, but the problem was I could not perfectly recall the definitions of the several principles that I could remember!
Abstract: Some of the names of these principles that come immediately to mind are such principles as person involvement, growth orientation, hope, self-determination and choice. My next problem was I could not perfectly recall the definitions of the several principles that I could remember! If I could not remember all these important principles and their definitions, then how could these principles serve as my ready guide? My just diagnosed deficit in “remembering key principles” had me thinking further. Is there not just one simple principle that transcends all these others, a superordinate principle from which all other principles emanate? I think there is, and it is the principle of personhood. The personhood principle is defined simply as, “ people with severe mental illnesses are people.” I know what some of you are saying to yourself. “Duh—this is too simple and obvious… and besides we already know about applying this principle to what we do.” I think not. Recently I was reading an excellent article in this Journal and a certain sentence grabbed at my throat. “What may be particularly striking about the findings of this study is that Aristotle's insight about the necessity of friendship appears just as relevant to those of us with psychiatric disabilities as to anyone else” (Davidson et al., 2001, p. 290). What is even more striking to me is that more than 2000 years after Aristotle's comments, our field finds this notion a revelation! A revelation not unlike the surprise when we learned that many people with severe mental illnesses wanted to work, or set their own goals, or fall in love.

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TL;DR: A two-volume set on recovery, published by Boston University's Center for Psychiatric Rehabilitation, was edited by three doctorate psychologists, Larry Davidson, Courtenay Harding, and LeRoy Spaniol, experts in the field of psychosocial rehabilitation with experience as researchers as mentioned in this paper.
Abstract: Psychiatry is in an era of change not only in terms of new scientific models of mental health but also in values-based models of psychiatric service. Our nation’s first two commissions on mental health were appointed by President Kennedy in 1963 and by President Carter in 1978. The third commission, the New Freedom Commission appointed by George W. Bush, sets a vision for recovery in its budget-neutral document, Achieving the Promise (1). “Recovery” is becoming more than a word. It is a possible juggernaut of hope and transformation. This two-volume set on recovery, published by Boston University’s Center for Psychiatric Rehabilitation, was edited by three doctorate psychologists, Larry Davidson, Courtenay Harding, and LeRoy Spaniol, experts in the field of psychosocial rehabilitation with experience as researchers,

49 citations

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TL;DR: Familial factors may select individuals into some of the established risk environments for DP, and studies investigating the causes of DP need to take such confounding into account.
Abstract: Purpose The incidence of disability pension (DP), especially due to mental diagnoses, has increased in many countries, but knowledge of socio-demographic risk factors for DP is limited. Further, the influences of genetics and early-life factors (jointly called familial factors) on these associations remain to be studied. The aims were to study incidence of DP (due to all and mental diagnoses) and associations with socio-demographic factors, and also to establish whether associations differ with DP diagnosis and sex, and are influenced by familial factors.

47 citations

Journal ArticleDOI
TL;DR: A statistically and clinically significant improvement in functioning was observed among patients treated with the VADO approach.
Abstract: Objective: This study investigated whether a specific structured planning and evaluation approach called VADO (in English, Skills Assessment and Definition of Goals) resulted in improved personal and social functioning among patients with chronic schizophrenia. Methods: A total of 85 patients with chronic schizophrenia who were under a stable medication regimen were randomly allocated to the VADO-based intervention or to routine care; 78 completed the program. Interventions were carried out in nine Italian day treatment or residential rehabilitation facilities. Assessment at the beginning of the study and at the oneyear follow-up included the Personal and Social Performance scale (PSP) and Brief Psychiatric Rating Scale Version 4.0 (BPRS). Clinically significant improvement was defined as an increase of at least 10 points on the PSP or a decrease of at least 20 percent on the BPRS total score. Results: At baseline, average PSP scores in the experimental group and in the control group were 33.9±8.1 and 34.0±11.2, respectively (possible scores range from 1 to 100, with higher scores indicating better functioning). At six months, the score improved markedly in the experimental group (40.8±10.9) and minimal change was observed in the control group (35.3±11.6); the difference between groups was significant (difference of 6.9 points compared with 1.3 points; t=2.21, df=81, p<.05). At 12 months, the same trend was observed (difference of 12.0 points compared with 3.5 points), and the difference between groups was both statistically and clinically significant (t=2.99, df=75, p<.01). Conclusions: A statistically and clinically significant improvement in functioning was observed among patients treated with the VADO approach. (Psychiatric Services 57:1778–1783, 2006)

44 citations

Frequently Asked Questions (2)
Q1. What are the future works in this paper?

A possible conclusion is that an intervention such as BPR that focuses on the relationship between a 12 person ’ s self-formulated goals and their values for the future promotes health related issues and facilitates recovery. A further argument was that there is a rather widespread implementation of the BPR approach but a lack of clinical studies focusing the evidence of the approach. A further issue of concern is whether the population in the actual community setting is a representative group of clients with SMI. In spite of these limitations the authors still suggest that the BPR approach can be an important factor in improving clients ’ clinical and social situation. 

Unless other specific re-use rights are stated the following general rights apply: Copyright and moral rights for the publications made accessible in the public portal are retained by the authors and/or other copyright owners and it is a condition of accessing publications that users recognise and abide by the legal requirements associated with these rights. You may not further distribute the material or use it for any profit-making activity or commercial gain •