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

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

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.

Figures

Table 3. Changes in the clients’ contact pattern with care and service between baseline and the two-year follow-up (n=49)

Table 4. Comparisons for health outcomes between clients with high/low goal attainment (n=49)

Table 2. Outcome measures at baseline and the two-year follow-up N= 49

Table 1. Sociodemographic characteristics of clients who completed the study (n= 49) versus drop out clients (n=22).

Full text

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"Choose–Get–Keep Model (CGK)"

Frequently asked questions

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. 

Q2. What are the contributions in this paper?

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 •