Bridging the Gap: Using Microsociological Theory to Understand How Expressed Emotion Predicts Clinical Outcomes

Research has shown that EE among families is a strong predictor of relapse for people with severe mental illness. Recent studies have also found the presence of EE in consumer-provider relationships. Despite high consistency in the findings related to EE and relapse, the concept has weak validity as little is known about how exactly it triggers relapse. Microsociological theory provides a framework with which to analyze social interaction and, more specifically, understand how interactions relate to the emotions of pride and shame. By identifying the components of interaction rituals, the theory provides insight into the key processes underlying EE and demonstrates how methodologies based on direct observation have the potential to measure EE with greater validity. This article describes how microsociological theory can be applied to the concept of expressed emotion (EE)

Capturing the value of peer support : measuring recovery-oriented services

Purpose: The purpose of this paper is to examine the gap between recovery-oriented processes and clinical outcomes in peer support, an exemplar of recovery-oriented services, and offer suggestions for bridging this gap. Design/methodology/approach: This viewpoint is a brief review of literature on peer support services and gaps in outcome measurement towards building an evidence base for recovery-oriented services. Findings: Clinical outcomes like hospitalizations or symptoms remain a focus of research, practice and policy in recovery-oriented services and contribute to a mixed evidence base for peer support services, in which recovery-oriented outcomes like empowerment, self-efficacy and hopefulness have more evidentiary support. One approach is to identify the theoretical underpinnings of peer support services and the corresponding change mechanisms in models that would make these recovery-oriented outcomes mediators or process outcomes. A better starting point is to consider which outcomes are valued by the people who use services and develop an evaluation approach according to those stated goals. User driven measurement approaches and more participatory types of research can improve both the quality and impact of health and mental health services. Originality/value: This viewpoint provides a brief review of peer support services and the challenges of outcome measurement in establishing an evidence base and recommends user driven measurement as a starting point in evaluation of recovery-oriented services

Person-centered planning in mental health : a transatlantic collaboration to tackle implementation barriers

Collaborative, person-centered approaches to care planning are increasingly recognized as instrumental in supporting attainment of personal recovery outcomes. Yet, while much is known about factors which support person-centered planning, successful implementation often remains an elusive goal. This paper reviews international efforts to promote Person-Centered Care Planning (PCCP) in the context of a randomized clinical trial in the United States and in the “Meaningful and Measurable” initiative, a collaborative action research project involving diverse provider organizations in Scotland. The authors review the history of international efforts to implement PCCP and offer preliminary evidence regarding its positive impact on both process outcomes (i.e., the nature of the primary therapeutic relationship and the service-user’s experience) and personal recovery outcomes (e.g., quality of life, community belonging, and valued roles). PCCP will be defined through description of key principles and practices as they relate to both relational aspects (i.e., shifts in stakeholder roles and conversations) and documentation/recording aspects (i.e., how person-centered relationships are captured in written or electronic records). Similarities and differences across the US and Scottish experience of person-centered care planning will be highlighted and a series of recommendations offered to further implementation of this essential recovery-oriented practice

The role of process: Examining consumer -provider service interactions

Objective. The recovery movement has affirmed the importance of consumer-provider relationships for people with severe mental illness (SMI). This naturalistic study examined the process of providing Assertive Community Treatment (ACT) services to homeless persons with SMI. ACT is an intensive case management model targeted towards hard-to-engage consumers. Although there has been extensive research on the structure of case management models, the actual process of engaging and maintaining consumers in services remains an understudied aspect of case management that may have considerable impact on consumer outcomes. The study examined consumer-provider relationships, coercion, and their impact on quality of services from both the provider and consumer perspective. Methods. Two focus groups were conducted with consumers and providers to explore consumer-provider relationships. Seventy individual service contacts were sampled for the quantitative part of the study. Case managers and consumers completed interviews measuring socio-demographic characteristics, service contact characteristics, consumer-provider relationships, utilization of coercive strategies, perceived coercion, and quality of service contact. Parallel measures distinguished between case manager and consumer perspectives. Multivariate regression analyses examined the effect of consumer-provider relationships and coercion on quality of service contact. Results. Consumer-provider relationships and perceived coercion, rather than utilization of coercive strategies, were strongly associated with quality of service contact. Consumer and case manager perspectives diverged, with consumer measures explaining the variance in outcomes more than case manager measures. Focus group findings illustrated the differences between the case manager and consumer perspectives, with case managers viewing the relationship as a means to obtain service goals, whereas consumers valued these relationships for their own sake. Conclusion. Findings demonstrate that, for consumers, quality of service is associated with positive consumer-provider relationships and not feeling coerced. With consumers whose connection to services is tenuous, immediate positive response to service interactions is vital to maintain engagement. Case managers need to have the clinical skills to understand the consumer perspective and prioritize the relationship within service provision. More evidence related to the process of service provision will facilitate translation of research to practice and promote recovery oriented services

The role of process: Examining consumer -provider service interactions

Objective. The recovery movement has affirmed the importance of consumer-provider relationships for people with severe mental illness (SMI). This naturalistic study examined the process of providing Assertive Community Treatment (ACT) services to homeless persons with SMI. ACT is an intensive case management model targeted towards hard-to-engage consumers. Although there has been extensive research on the structure of case management models, the actual process of engaging and maintaining consumers in services remains an understudied aspect of case management that may have considerable impact on consumer outcomes. The study examined consumer-provider relationships, coercion, and their impact on quality of services from both the provider and consumer perspective. Methods. Two focus groups were conducted with consumers and providers to explore consumer-provider relationships. Seventy individual service contacts were sampled for the quantitative part of the study. Case managers and consumers completed interviews measuring socio-demographic characteristics, service contact characteristics, consumer-provider relationships, utilization of coercive strategies, perceived coercion, and quality of service contact. Parallel measures distinguished between case manager and consumer perspectives. Multivariate regression analyses examined the effect of consumer-provider relationships and coercion on quality of service contact. Results. Consumer-provider relationships and perceived coercion, rather than utilization of coercive strategies, were strongly associated with quality of service contact. Consumer and case manager perspectives diverged, with consumer measures explaining the variance in outcomes more than case manager measures. Focus group findings illustrated the differences between the case manager and consumer perspectives, with case managers viewing the relationship as a means to obtain service goals, whereas consumers valued these relationships for their own sake. Conclusion. Findings demonstrate that, for consumers, quality of service is associated with positive consumer-provider relationships and not feeling coerced. With consumers whose connection to services is tenuous, immediate positive response to service interactions is vital to maintain engagement. Case managers need to have the clinical skills to understand the consumer perspective and prioritize the relationship within service provision. More evidence related to the process of service provision will facilitate translation of research to practice and promote recovery oriented services

Shared decision making within the context of recovery-oriented care

Purpose: This article will consider the role of shared decision-making as one component of recovery-oriented care. Design/Methodology/Approach: This article is conceptual and reviews literature relevant to recovery-oriented care, person-centered recovery planning, and shared decision-making. Findings: To the degree to which shared decision-making offers tools for sharing useful information about treatment options with service users and family members or other loved ones, it can be considered a valuable addition to the recovery-oriented armamentarium. It is important to emphasize, though, that recovery-oriented practice has a broader focus on the person’s overall life in the community and is not limited to formal treatments or other professionally-delivered interventions. Within the more holistic context of recovery, shared decision-making regarding such interventions is only one tool among many, which needs to be integrated within an overall person-centered recovery planning process. More emphasis is given within recovery-oriented care to activating and equipping persons for exercising self-care and for pursuing a life they have reason to value, and the nature of the relationships required to promote such processes will be identified. In describing the nature of these relationships, it will become evident that decision-making is only one of many processes that need to be shared between persons in recovery and those who accept responsibility for promoting and supporting that person’s recovery. Originality/Value: By viewing shared decision-making within the context of recovery, this article provides a framework that can assist in the implementation of shared decision-making in routine mental health care