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Psychosis in Public Mental Health: Provider Perspectives on Clinical Relationships and Barriers to the Improvement of Services



Whereas a growing literature has sought to understand challenges involved in the dissemination and implementation of specific evidence-based practices (EBP), few studies have centered on the perspectives of front-line community providers regarding best practices, clinical ideals and barriers to quality improvement for clients with psychosis. The goal of this project was to lay a foundation for future work aimed at improving the overall quality and impact of the multifaceted services typically provided to adults with psychosis served by the public mental health system. The findings reported here draw on a series of in-depth interviews and focus groups with 34 clinicians based at multiple inner-city community mental health sites. The project was participatory and service user co-led. Analyses focus on participant’s perspectives concerning optimal services for clients with psychosis and perceived barriers to improving services. Providers strongly underscored the centrality of relationship quality versus mastery of specialized techniques and of deeper experiential engagement with the subjective meaning of the experience of psychosis. Asked about barriers to quality improvement, they described both macrolevel social forces, including chronic underfunding and overreliance on manualized approaches to distress, as well as cross-cutting clinical challenges not typically captured in the literature on more specific, targeted interventions. Our discussion focuses on the implications of these findings with respect to research and quality improvement and concludes with a call to increase investment and attention to the perspectives of front-line providers and the issue of workforce and organizational capacity vis-à-vis psychosis.
American Journal of Orthopsychiatry
Psychosis in Public Mental Health: Provider Perspectives
on Clinical Relationships and Barriers to the
Improvement of Services
Nev Jones, Cherise Rosen, Shirley Helm, Sheila O’Neill, Larry Davidson, and Mona Shattell
Online First Publication, July 16, 2018.
Jones, N., Rosen, C., Helm, S., O’Neill, S., Davidson, L., & Shattell, M. (2018, July 16). Psychosis in
Public Mental Health: Provider Perspectives on Clinical Relationships and Barriers to the
Improvement of Services. American Journal of Orthopsychiatry. Advance online publication.
Psychosis in Public Mental Health: Provider
Perspectives on Clinical Relationships and Barriers to
the Improvement of Services
Nev Jones
University of South Florida Cherise Rosen
University of Illinois at Chicago
Shirley Helm and Sheila O’Neill
Thresholds Larry Davidson
Yale University
Mona Shattell
Rush University
Whereas a growing literature has sought to understand challenges involved in the dissemination
and implementation of specific evidence-based practices (EBP), few studies have centered on the
perspectives of front-line community providers regarding best practices, clinical ideals and
barriers to quality improvement for clients with psychosis. The goal of this project was to lay a
foundation for future work aimed at improving the overall quality and impact of the multifaceted
services typically provided to adults with psychosis served by the public mental health system.
The findings reported here draw on a series of in-depth interviews and focus groups with 34
clinicians based at multiple inner-city community mental health sites. The project was partici-
patory and service user co-led. Analyses focus on participant’s perspectives concerning optimal
services for clients with psychosis and perceived barriers to improving services. Providers
strongly underscored the centrality of relationship quality versus mastery of specialized tech-
niques and of deeper experiential engagement with the subjective meaning of the experience of
psychosis. Asked about barriers to quality improvement, they described both macrolevel social
forces, including chronic underfunding and overreliance on manualized approaches to distress,
as well as cross-cutting clinical challenges not typically captured in the literature on more
specific, targeted interventions. Our discussion focuses on the implications of these findings with
respect to research and quality improvement and concludes with a call to increase investment and
attention to the perspectives of front-line providers and the issue of workforce and organizational
capacity vis-a
`-vis psychosis.
Public Policy Relevance Statement
While a significant amount of research has focused on the effectiveness and implementation
of specific interventions for psychosis, policy, and/or programmatic work designed to bolster
capacity and quality across a given agency or set of linked services has received much less
Nev Jones, Department of Mental Health Law & Policy, Louis de la Parte
Florida Mental Health Institute, University of South Florida; Cherise Rosen,
Department of Psychiatry, School of Medicine, University of Illinois at Chicago;
Shirley Helm and Sheila O’Neill, Thresholds, Chicago, IL; Larry Davidson,
Program for Recovery & Community Health, Department of Psychiatry, Yale
University; Mona Shattell, Department of Community, Systems and Mental
Health Nursing, College of Nursing, Rush University.
I thank the individuals who participated in this study and those that
helped with the data collection process including Angelica Gomez and
Nancy Little.
Correspondence concerning this article should be addressed to Nev
Jones, Department of Mental Health Law & Policy, Louis de la Parte
Florida Mental Health Institute, University of South Florida 13301
Bruce B Downs Blvd, MHC2732, Tampa, FL 33612. E-mail: genevra@
This document is copyrighted by the American Psychological Association or one of its allied publishers.
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
American Journal of Orthopsychiatry
© 2018 Global Alliance for Behavioral Health and Social Justice 2018, Vol. 1, No. 999, 000
attention. The research described here underscores the importance of greater attention to
broader service improvement strategies including those focused on building workforce and
organizational capacity and addressing or accommodating key policy and fiscal constraints.
Clients with psychosis in the public mental health system are both a high risk and notably
underserved group, particularly in the United States. Our findings underscore the challenges
providers face in adequately meeting client’s clinical needs, and frequent lack of either past
or concurrent training with a specialized focus on psychosis. Great efforts to meet the unique
needs of persons with psychosis appear warranted. Providers in our sample stressed a
preference for more humanistic or meaning-centered approaches to psychosis, and criticisms
of what they perceived to be a growing emphasis on manualization, mechanization, and
narrow mastery of specific techniques. Patient-centered and comparative effectiveness re-
search aimed at unpacking the relative impact of the such approaches with current gold
standard manualized interventions has the potential to help clarify and guide efforts to
achieve transformative change within the mental health system and more fully realize the
ideals of recovery-oriented, patient-centered services.
In recent years, community mental health (CMH) researchers
have placed increasing emphasis on the investigation of bar-
riers to the implementation of specific, generally evidence-
based, interventions or approaches, a field often described as
“dissemination and implementation science” (DI; Schoenwald,
McHugh, & Barlow, 2012). Critics of conventional DI, however,
have expressed concerns regarding an overemphasis on “already
packaged programs”— often interventions developed in academic
settings with resources not commonly available in the community,
rather than similar community settings (Atkins, Rusch, Mehta, &
Lakind, 2016; Weisz, Ng, & Bearman, 2014)—and overly rigid
fidelity protocols and criterion. This critical body of literature has
also drawn attention to specific disconnects between community
and academic sites including differences in organizational capacity
(Kelleher, 2010), the training and supervision of providers, and
ecological misalignment between at least some academic interven-
tion development and testing and the constraints of underresourced
public mental health agencies (Santucci, Thomassin, Petrovic, &
Weisz, 2015; Weisz et al., 2014).
Disconnects between intervention research and everyday
clinical practice are further foregrounded in studies document-
ing practicing clinicians’ often skeptical attitudes regarding the
usefulness of academic research (e.g., Stewart & Chambless,
2007; Stewart, Stirman, & Chambless, 2012). Drawing on in-
depth interviews with practicing clinicians, for example, Stew-
art and colleagues (2012) conclude that providers can harbor
significant doubts about the applicability of findings from clin-
ical trials to their clients as well as concerns about the potential
misuse of research findings to narrowly dictate rather than
inform clinical practice. A survey project aimed specifically at
active researchers who simultaneously maintained a clinical
practice found similar attitudes: empirical research was still
rated as less helpful than a wide variety of other sources of
information, including direct clinical experience and learning
from clients (Safran, Muran, & Eubanks-Carter, 2011). Other
research suggests that even when relatively rigid practices are
ostensibly mandated by policy, providers tend to adhere to their
own clinical values and to continue to practice with greater
flexibility than policy dictates (Arnd-Caddigan, 2012).
Common factors theory, which holds that much of the effec-
tiveness of ostensibly diverse therapeutic approaches (and specific
evidence based practices) in fact stems from common underlying
factors arguably complements the above findings (Barth et al.,
2012; Blow, Sprenkle, & Davis, 2007; Laska, Gurman, &
Wampold, 2014), redirecting attention to cross-cutting processes
and dynamics thought to undergird change. Laska et al. (2014), for
example, argue that the overall impact of such factors as client-
therapist consensus over goals and methods, empathy and trust,
and affirmation account for substantially more of the variance in
client therapy outcomes that the specific treatment method or
approach. A recent analysis of the impact of therapeutic alliance
(TA) on outcomes in response to cognitive– behavioral therapy for
psychosis (CBTp), for instance, found that therapeutic alliance
actually exerted a causal effect on outcomes: with good TA atten-
dance of more sessions improved symptomatological outcomes,
whereas poor TA combined with good attendance was actually
detrimental to the service user and exacerbated psychopathology
(Goldsmith, Lewis, Dunn, & Bentall, 2015).
From an ecological perspective, common factors such as ther-
apeutic alliance do not arise in an interpersonal vacuum, but are
instead shaped by the social and structural contexts in which the
provider and the service user are embedded. These contexts in-
clude the clinical supervision of the provider (Rousmaniere, Swift,
Babins-Wagner, Whipple, & Berzins, 2016), the organizational
culture in which clinical interactions occur (Hemmelgarn, Glisson,
& James, 2006), and the service user’s history of attachment-
related trauma (Lysaker, Davis, Outcalt, Gelkopf, & Roe, 2011)
and structural disadvantage (Smith, Li, Dykema, Hamlet, & Shell-
man, 2013).
Psychosis in Public Mental Health
A separate set of issues is relevant to the examination of public
mental health services for persons with psychosis more specifi-
cally. Whereas many evidence-based practices in the field of
clinical psychiatric rehabilitation have been developed and tested
in samples with high rates of psychotic disorders—for example
assertive community treatment, individual placement and support,
and integrated dual diagnosis treatment—therapeutic approaches
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specific to psychosis such as cognitive– behavioral therapy for
psychosis (CBTp), remain widely underimplemented and/or un-
available in the United States, particularly in community settings
(Mueser & Noordsy, 2005; Riggs, Wiltsey-Stirman, & Beck,
2012). In contrast, specialized early intervention in psychosis
services have begun to take hold over the past decade (Dixon,
2017); however, inclusion is generally limited to a two-year period
following initial onset. Standard adult mental health services typ-
ically provide generalist programs targeting such areas as indepen-
dent living, substance use issues, or general well-being, rather than
providing specialized clinical interventions for psychosis. While
we were unable to locate research specifically focused on longi-
tudinal changes in the overall balance of therapy and medications
accessed by persons with psychosis in the United States, research
on trends in the treatment of mental illness more broadly suggests
that access to therapy has remained flat while the use of psycho-
tropics only (without psychotherapy) has substantially increased
(Olfson & Marcus, 2010).
The Current Project
Although the literature reviewed previously provides a strong
rationale for research attentive to the broader contexts of public
mental health, there is a surprising scarcity of publications focused
on factors and constraints shaping therapeutic engagement with
individuals with psychosis and their experiences within the U.S.
public mental health sector. The major aims of the work described
here were to better understand provider’s:
(1) values and ideals with respect to working with/serving
clients experiencing psychosis;
(2) current state of services and perceived barriers to improving
these services for clients with psychosis.
In the context of the existing literature, our goal was to lay some
of the initial groundwork for intervention and/or policy changes
needed to improve the overall experience of the typically multi-
faceted and multicomponent services received by clients with
psychosis served within the public mental health system and
ultimately their impact.
The research described in this article is grounded in four focus
groups with 32 front-line clinicians, and 2 additional individual
interviews with senior administrative and/or training staff unavail-
able for the focus groups (total n34). All research was approved
by the DePaul University institutional review board (IRB
MS112012NUR-R4), and all clinician participants provided in-
formed consent. Interviews were conducted as the second phase of
a two year project, with Year 1 entailing approximately 100 hr of
ethnographic observation by the first author, including shadowing
assertive community treatment home visits, attending therapeutic
groups, attending provider trainings, and spending extended peri-
ods at drop-in centers and residential programs. The ethnographic
component of the project was designed to provide deeper insights
into the contexts in which providers worked and while ethno-
graphic findings are not reported in this paper, they provided
important context to understanding and interpreting the subsequent
qualitative work. Recruitment entailed purposive sampling, driven
by the senior provider-based project lead. Specifically, efforts
were made to conduct focus groups with providers from different
program areas, and with varying levels of experience and exper-
tise. Two of the focus groups involved entire community support
teams, one consisted of more senior leadership as well as super-
visors from multiple programs, and one consisted of all current
doctoral-level clinical psychology interns at the agency. Agency
leadership handled recruitment as well as the scheduling of inter-
views; the first author led all focus groups.
The project utilized robust participatory methods with all re-
search decisions shaped by a research advisory board (RAB) that
included both clients (service users) and providers and that met
monthly throughout the project lifecycle. For example, the RAB
helped determine who should be included in focus groups in order
to maximize the diversity of views and experiences, collabora-
tively designed specific questions and reviewed the focus group
guides. A subset of the members of the project RAB also partic-
ipated in the ongoing work of interpretation and analysis—for
example, reading and revising multiple versions of the article.
The clinician focus groups and interviews centered on partici-
pants’ clinical goals and values vis-a
`-vis psychosis (“please de-
scribe your approach to working with clients with psychosis”),
their understanding of optimal engagement with clients and the
experience of psychosis (“what do you think it means to engage
with clients and their experiences”), personal challenges (“what do
you personally find most challenging about working with clients
with psychosis”), and perceived barriers to quality improvement
(“what do you see as the major barriers to improving services for
clients with psychosis within your program”). Protocol questions
were open-ended but explicitly included multilevel prompts to
elicit clinician participants’ views on broader policy and systems-
level factors as well as interpersonal variables. Focus groups were
Following data collection, recordings were transcribed verbatim
and integrated with additional notes that captured nonverbal infor-
mation such as nods, raised hands, and other nonverbal indications
of agreement. In many cases, these nonverbal communications
were used to gauge the strength of particular themes and their
resonance with other participants (and are noted as such in our
analyses). The transcripts were coded using a constructivist
grounded theory approach (Charmaz, 2014), with a focus on
identifying core underlying themes (that in many cases cut across
the discussions following different questions). The first author and
a research assistant each independently coded two focus group
transcripts, discussed coding and arrived at a semifinal coding
schema by consensus. The themes were then refined in dialogue with
the original RAB. After a further round of reliability checks, all
transcripts were coded by the first author. In reporting findings, we
have numbered participants in order to distinguish comments from
different individuals (e.g., Clinician 1, Clinician 2, Clinician 3).
Agency Context
The host community mental health agency (CMHA), employs
over 500 staff covering a large urban center as well as suburban
areas, spanning multiple counties. Clients served by the agency
virtually all met criteria for “severe mental illness” and receive
public benefits tied to significant functional disability. Approxi-
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This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
mately three quarters of the agency’s services are provided in the
community, with staff generally working as part of a team to meet
a range of service user needs. The CMHA also runs residential and
transitional housing programs, and fieldwork for the project was
split between residential sites and the shadowing of clinicians on
home visits. A typical day for a community-based team member
might consist of 2– 4 outreach visits, potentially including activi-
ties such as grocery runs or transportation to a physical health
appointment. For staff at residential sites, daily work would typi-
cally involve a combination of cooking with residents, outreach
oriented toward locating housing or external supports, as well as
individual planning meetings and peer support, social skills, or
therapeutic groups. Just over half of the agency’s total staff have
a bachelor’s degree or less, with the remaining clinicians possess-
ing a master’s degree, typically in social work or counseling.
Clinician participants consisted of 6 men and 28 women adults
representing different CMHS sites and programs; all provided
either front-line community-based clinical care and outreach or
direct supervision of front-line community-based workers. With
the exception of three doctoral level clinical psychology trainees,
no other staff provided office-based therapy; instead, even those
clinicians with substantial psychotherapeutic training were respon-
sible for a range of broader community case management services
including in-home medication management, service coordination,
and provision of specific evidence-based practices in the areas of
employment and illness self-management. The majority were Cau-
casian (82%), and the average age was 35. Three participants were
clinical psychology doctoral interns, 1 working clinician had a
clinical psychology doctorate, 5 were bachelor’s level mental
health workers, and the remainder were master’s level clinicians
with degrees in either social work, counseling, or nursing. Five of
the participants were designated team leaders and/or clinical
Qualitative Findings
Findings are organized into three overarching categories: (a)
service and engagement values (or participant’s clinical ideals); (b)
detrimental macrolevel constraints on service quality (structural
and political reasons why clinical ideals may go unrealized); and
(c) more proximal clinical challenges tied to the multifaceted,
multicomponent nature of holistic adult behavioral health services.
Service and Engagement Values
Centrality of the therapeutic relationship. Overall,
clinician participants repeatedly reiterated their belief in the ther-
apeutic relationship both as the foundation of quality services as
well as a fundamental element of practice and ultimately outcome.
That is, relationships between clients and providers were fre-
quently described as a scaffolding in which the dynamic alchem-
ized a positive outcome, for example:
Clin 1: “so much of a human being’s psychological well-
being is based off of being able to have meaningful
relationships with other human beings. If you’re not
able to do that, then anxiety, depression, delusions,
psychosis can very easily set in for anyone. So to be
able to use the tools that we have and to help people
to increase their ability to be authentic and vulnerable
in more situations is super beneficial. I think that the
best way to do that is to model it ourselves [through
the relationship].”
Clin 2: “For me, in any clinical work that I do, I take it as an
approach of ‘we’re in a relationship together.’ I am a
human being in this, you’re a human being in this,
together we create something that hopefully changes
me, and it also changes you.”
In contrast, particular techniques or practices (e.g., specific
forms of therapy, tools, or manualized practices) were described as
secondary and best used in a flexible way—for example, “as
needed” or “as they appeal to the service user.” Similarly, clinical
intuition, rather than specialized knowledge, was repeatedly in-
voked—“it’s less a matter of having formal skills or techniques
than it is an intuitive understanding, attunement to people” ex-
plained one, while others referenced “an intuitive sense” or “intu-
itive abilities.” Participants also affirmed a strong belief in per-
sonalized support: “I think not just approaching it in just a one-
size-fits-all [way], like here’s the intervention that’s been shown to
work, but, what does this mean for that specific person? What does
that feel like to you, to be walking around with that?”
Engaging with the subjective meaning of
psychosis. Taking an emphasis on relational quality one step
further, many clinician participants explicitly emphasized the im-
portance of engaging not only with the “normal” aspects of clients
(i.e., as people) but also with “the meaning of their [psychotic]
experiences,” including perceived connections to life events, and
voice or belief content tied to cultural, spiritual, and/or political
experiences and convictions. As a psychology intern in one group
explained: “A lot of us have this notion that it’s our job to get them
to come back to reality, that it’s our job to get them to speak our
language, but a lot of us don’t take the time to speak their language
and to enter the delusion—not in a way that reinforces it or enables
it, but in a way to really understand what it means for the client.
[When I encounter some new and challenging symptom] I’m not,
“Oh, my gosh, I haven’t done this before. Let me step back and
read a couple books before I intervene.” It’s more of a way of just
interacting with the person.” “The making meaning piece,” partic-
ipants in a different group concurred, “is just—it’s essential.”
Cutting across these discussions of meaning was a belief that
psychotic symptoms must be taken seriously—that is, understood
as experiences that should be explored and discussed on the
client’s own terms.
The Current State of Services Vis-a` -Vis Clients
with Psychosis Within Their Agency
Detrimental macro-level constraints. Ultimately the
bulk of conversation across the focus groups and interviews re-
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This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
volved around perceived macrolevel as well as more proximal
clinical and interpersonal challenges (covered in the final section).
While the macrolevel constraints are broken down into subthemes
for clarity of presentation, in the focus group conversations it was
clear that these were understood to be interconnected and syner-
gistic, at turns driving and/or reinforcing one another. Subthemes
are: the broader sociopolitical marginalization of serious mental
illness; constraints imposed by billing and funding mechanisms;
staff preparation; and the mechanization of behavioral health
Ripple effects of broader societal marginalization.
Clinician participants consistently invoked the broader marginal-
ization of serious mental illness—reflected in societal stigma and
media representation, funding allocations relative to other social
issues, provider compensation levels and perceived status, minimal
training in serious mental illness in clinical training programs
across disciplines as areas of major structural drivers of policy and
practice. While funding itself was perceived as the single biggest
issue, participants described a number of synergistic ways in which
underfunding helped engender other forms of marginality. For
example, public mental health services in their metro areas, par-
ticipants noted, tended to be concentrated in defined “service
ghettoes”—typically parts of town with high rates of violence and
crime, crumbling infrastructure, and food deserts. The location
(and state) of these programs, in turn, served as a barrier to
recruiting and retaining staff. “There’s some places people just
aren’t willing to work,” one manager explained “or at least not
many people.” Another described bed bugs as “a very real risk” for
outreach workers, and participants noted that even some service
sites were infested, and staff had to be instructed to take steps to
reduce infestations of their own cars, bags, or gear. One clinician
described recent gang violence in the area surrounding her pro-
gram noting that “the staff get to leave but the [clients] don’t” and
wondering aloud “what does that constant risk of violence do to
people who already experience paranoia.”
Billing. Standard, contemporary billing practices were also
widely viewed as an impediment to quality care. Clinician partic-
ipants repeatedly noted the negative consequences of clinical pro-
ductivity targets and quotas, including the amount of time spent
documenting services and/or justifying medical necessity rather
than meeting with clients, widely viewing such expectations as
particularly detrimental to clients with psychosis for whom more
time might be needed or to build rapport and gain trust. While their
frustration was evident, many participants nevertheless conveyed
an air of resignation in that: “Funding structure doesn’t allow it
[deeper and more innovative practice].”
Explaining the erosion of funding over time, a senior clinical
administrator noted that “Staff are now not [even] able to visit
people in the hospital, can’t go to their funerals, because it’s not
billable. Your job is to serve this function and who cares about the
humanity. We try to find ways to let people go [e.g. to funerals],
but it means we have to swallow the costs because the time is not
Staff preparation and retention. Clinician partici-
pants across all our clinician focus groups— but particularly su-
pervisors—also emphasized the challenges of recruiting and re-
taining talented clinicians in the context of public mental health. A
senior clinical administrator described those experienced, senior
staff with the possibility to work outside of CMHS for greater pay
who had nevertheless opted to remain in the public sector as a
“select group” who “actively choose to serve the folks with the
highest needs.” Consequently, administrators must grapple with a
mix of the very talented individuals with the majority of staff
entering the system with little to no experience working with
psychosis. As one senior clinician noted, much of the counseling
curricula for local master’s programs revolves around mild depres-
sion, anxiety, and adjustment issues “nothing like what many of
[our agency’s] clients are facing.” Clinicians hired from other local
agencies, in-the-field training and clinical supervision were de-
scribed as typically neutral at best, and at worst, as having encour-
aged negative attitudes toward those with more stigmatized con-
ditions such as psychosis: “not only do we have to teach them what
to do, we also have to undo a lot of past learning that has led to an
entrenched belief in chronic disability.” Only three participants
noted any dedicated training in clinical work or therapy specific to
psychosis while in graduate school: in one case a single-day
workshop and for the others courses or supervision by instructors
who “happened” to have an explicit interest asked about continu-
ing education opportunities. Most participants described going
years without a single psychosis-related CEU having been avail-
able. Interestingly, many welcomed and praised a recent new
internal training revolving around an auditory hallucination simu-
lation exercise indicating that staff interest in such topics is high.
Perceived Barriers to Improving Services for
Clients With Psychosis
The mechanization of clinical work and
intervention. Clinician participants also commented on the
changing landscape of clinical best practices, in particular report-
ing what they perceived as the increasing mechanization, manual-
ization, or “reductionist” tendencies of contemporary clinical
Reflecting on contemporary trends, for example, participants in
one group reflected:
Clin 1: “To be good at [working with voices/psychosis], a
certain amount of [struggling together] is necessary.”
Clin 2: “It’s a more relational way of working.”
Clin 1: “Right.” [Multiple participants sigh in agreement,
shake their heads]
Clin 3: “Somewhere along the way that got taken out of the
mental health field, and more behavioral approaches
where the service user is seeing somebody that de-
livers an intervention [took over], but really—”
Clin 4: “Then you measure it.” [Multiple members shake
their heads, sigh]
Particularly from the vantage point of staff who had been in the
field for an extended period of time (15 years or more), these
trends went hand in hand with other changes noted previously,
including changes in documentation standards and associated “red
tape,” but also more rigid views regarding clinical boundaries.
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Similarly, the increased emphasis on community-based services
had, on the one hand, increased certain kinds of intimacy (e.g.,
visiting clients in their home) but reduced the casual interactions,
and “getting to know one another” opportunities common when
the majority of services were provided through day-programs,
drop-in centers, or residential facilities.
Proximal challenges and constraints. Moving down
to the level of interpersonal (micro) interactions and contexts,
participants laid out two major areas of difficulty with respect to
the improvement of services, relationships, and engagement with
clients with psychosis (and with their experiences): (a) balancing
more basic needs (and the service models designed to meet them)
with “deeper” clinical work and (b) negotiating boundaries as
providers move across the different roles and activities that in-
creasingly characterize best practice, team-based services.
Balancing basic needs and clinical work or
therapy. Providers were acutely aware of the extent to which
their clients struggle with basic needs, including food and housing,
as well as lack of transportation, and de facto segregation in
services and/or disadvantaged neighborhoods. They nevertheless
repeatedly affirmed a belief that deeper healing remained critically
important. “The trick,” observed one, “is how do you take all the
stuff you learned in grad school and utilize it in whatever you’re
doing, as you’re helping someone clean their toilet? As you’re
helping someone?” Different emphases emerged across the groups,
with one set of providers, for example, calling for more dedicated
one-to-one therapy and a reconfiguration of services to facilitate a
“two tiered system” in which “we have people who do case
management and care coordination and we have people who do
therapy,” while others simply described the challenge of balancing
both kinds of needs:
Clin 1: “We’re sometimes so geared toward making sure that
other things are done as far as the housing is stable,
other personal needs are taken care of. Not that the
psychosis comes second; but the safety, the housing,
food, all of those things are priority. Sometimes that
overshadows the work that I was trying to do as far as
the clinical part.”
Clin 2: “When I do more counseling-focused interventions,
then I feel like it comes back to bite me in the butt the
next day when I’m like, “Oh, crap, I didn’t call that
1– 800 number for the Link card because I did this
counseling intervention instead.” Sometimes it’s like
which one do they need more?”
Several participants also noted that while team-based models
(e.g., assertive community treatment and other community support
team frameworks) worked well in meeting holistic basic and
functional needs, they were less sure that such models were con-
ducive to more therapeutic work. As one explained: “We go see
people maybe two, three times a week, and it rotates who we see.
In terms of continuity with staff to [a particular] member it’s hard.
. . . I don’t know. I’m just aware of the weakness of the way the
models [e.g. individual therapy and team-based models] come
together or don’t come together. That affects what it looks like, or
how you could do it, or how much you [can actually do deeper
Negotiating boundaries across multiple roles and
spaces. Clinician participants emphasized the unique chal-
lenges negotiating multiple distinct roles crossing the areas of
counseling or clinical intervention, housing support, care coor-
dination, daily living, and self-care with clients experiencing
psychosis. For example, on any given day, a community team
member might end up helping a service user dole out their meds
for a week, or assisting with purchasing contraceptives, as well
as engaging in therapeutic work. In particular, the transversal of
different clinical and interpersonal boundaries and spheres of
intimacy was viewed as particularly challenging. As one par-
ticipant explained, “I had another member say to me before,
he’s like, ‘Well, we’re friends, right? Because I ride in your car
with you, and you let me pick the radio station, and you take me
out for coffee.’ Boundaries definitely get blurry.”
In each focus group, at least a subset of participants drew a more
explicit link between the multiple roles they held and risk of
finding themselves integrated into clients’ (ostensibly delusional)
belief systems. Examples provided included clients who “re-
cruited” (or attempted to recruit) the staff member into helping
protect them against other systems workers, for example general
physicians or parole officers, whom they thought had placed them
under surveillance, and those who reported voices that claimed
very specifically that certain staff members were friends, saviors,
or enemies.
Clin 1: “[A service user] told me the other day, he was like,
“You’re an angel, and God is speaking to me telling
me to marry you.” Now he’s calling me all the time
cuz he says that God told him to be in love with me
and marry me. [I do not know what to do.]”
Clin 2: “I was fortunate enough for a while to never be
included [in any service user’s delusions]. Then one
day, out of nowhere, it happened. . . . it feels like
tiptoeing a lot, I would say, cuz I feel like the longer
you know [this service user], the more you are in-
volved in the delusions. Sometimes she talks to me as
if I just know. Yeah, it’s a tricky dance that we do.”
Clin 3: “A guy who was a voice hearer, and one of his voices
ended up being my voice, was saying things that I
wasn’t saying or feeling. I, at the time, just took the
approach of being like, “I didn’t say that. Here’s what
is real about our relationship.” I do not know, now
I’m not sure if that was the best way to do it.”
Supervisors could provide at least some guidance navigating
these challenges, but clinician participants noted, little or any of
their formal training had prepared them for such challenges, and
they were unaware of any continuing education aimed at in-
creasing skill sets focusing primarily on psychosis. Specific
manualized interventions many were aware of, implemented,
and/or had trained in, one participant observed, “just don’t go
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This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
In the project described here, our goal was to explore pro-
vider views on service ideals and values vis-a
`-vis clients with
psychosis, the current state of services and perceived macro-
and microlevel constraints and barriers to quality improvement.
Providers within our sample consistently emphasized the foun-
dational importance of the therapeutic relationship rather than
mastery of specific techniques, and the value of engaging with
the subjective meaning of clients’ beliefs and experiences on
clients’ own terms. Participants described multiple macrolevel
factors that they felt worked against these ideals, including the
broader marginalization of serious mental illness, detrimental
billing procedures, provider turnover and lack of preparation,
and the increasing mechanization of mental health services.
Finally, participants noted two key interpersonal challenges:
balancing the basic needs of clients with “deeper” clinical work,
and navigating boundary issues stemming from the diverse
roles they frequently occupy, particularly in the context of
community-based, multidisciplinary service models.
Perhaps the most important upshot of this work is its re-
minder of the need for research and programmatic work focused
on strengthening agency’s and providers’ capacity to work with
psychosis across settings, roles, and program areas rather than
through the narrower implementation of specific interventions
(such a cognitive– behavioral therapy for psychosis group or
brief trauma focused intervention). As these analyses—and
important recent ethnographic projects (Brodwin, 2013; Myers,
2015)—suggest, providers in the public mental health system
typically interact with clients in multiple, multifaceted ways,
struggle to meet often overwhelming human needs (and degrees
of socioeconomic disadvantage) and navigate complex moral
and ethical challenges, all under the auspices of a heavily
bureaucratized and underresourced service system. The major-
ity of public health workers do not have any kind of license or
clinical degree (Hoge et al., 2009; Weil, 2015). Arguably,
discrete interventions better align with the larger field of bio-
medical research and clinical trial funding mechanisms, but beg
the question of whether other kinds of systemic workforce
training and support initiatives or organizational interventions
might more efficiently improve the quality of services (and
experiences of clients within them). As Kidd, Mckenzie, and
Virdee, 2014 highlight, in regards to inpatient care, the impor-
tance of general training (e.g., in recovery oriented care) is
critical in mental health reform regardless of the setting, and the
common factors literature may have much to contribute.
Our analyses also reinforce what we see as a growing push to
move from a science of implementation (understood as the
implementation of relatively rigid practices) to one of adapta-
tion, in which practices are modified or even fundamentally
reshaped in response to such local factors as “client emergent
issues,” provider knowledge and capacity, available resources
or resource constraints, and organizational characteristics (Aar-
ons et al., 2012; cf. Chambers & Norton, 2016; Greenhalgh,
Howick, & Maskrey, 2014). Under this kind of model, key
issues brought forward by our participants, such as the per-
ceived misfit between rotating team-based services and more
traditional therapy, could be used to make potentially substan-
tial model changes, rather than feeling stuck, as one of our
participants put it, with “the ways the models don’t come
In our sample, clinicians’ stated investment in “deeper” ther-
apeutic work, including what several participants described as a
“relational” way of engaging with the content and experience of
psychosis, is also worth noting. The vast majority of our sample
reported virtually no formal preparation relevant to such work,
including those with master’s and doctoral level training back-
grounds. Given the stakes of improving outcomes among clients
diagnosed with psychosis—arguably the single psychiatric dis-
ability subgroup at greatest risk of long-term unemployment,
homelessness, premature morbidity, and program disengage-
ment (Lally et al., 2017)—there is a pressing need to better
support the front-line staff who provide the majority of their
services, and to do so in a way that both emphasizes healing and
collaborative exploration (Corstens, Longden, McCarthy-Jones,
Waddingham, & Thomas, 2014; Thomas et al., 2014) and
effectively address challenges such as the complex interper-
sonal boundaries and the juggling of clinical and more basic
Limitations, Conclusions, and
Future Directions
Important limitations of the current article include that the
sample was drawn from a single agency in a single state, and one
whose service mandate limited eligibility to clients with estab-
lished and severe psychiatric disabilities. Throughout the focus
groups, clinicians described or referenced the presence of “less
skilled” providers at their agency in spite of explicit attempts to
diversify the sample based on experience, geographical area, and
relative skill or talent, participant comments, and level of knowl-
edge arguably suggested that we nevertheless ultimately over-
sampled skilled providers and/or those with a stronger commit-
ment to and interest in psychosis. It is also worth underscoring that
different states and different agencies handle the care of individ-
uals with serious mental illness (SMI) in a variety of ways, with
some providing far more dedicated office therapy than the partner
agency for this project.
Finally, although our study focused on psychosis, many of
the participant’s points were clearly broader in scope and ap-
plicable to clients in general, not just those with psychotic
disorders. Psychosis nevertheless raises particular questions
about collective meaning and cultural integration that arguably
merit additional scrutiny in the context of research, underscored
in our analyses by clinicians’ discussion of the particular chal-
lenges negotiating delusions and hallucinations in which they
had themselves become incorporated, and in meaning-focused
clinical work. While a growing chorus of publications in the
United Kingdom, Australia, and Europe have called for, or
pressed on with, such themes (Beavan & Read, 2010; Corstens
et al., 2014; Thomas et al., 2014), “meaning-centered” practice
remains seriously underdeveloped in the United States (Dillon
& Hornstein, 2013).
In summary, we see the primary contribution of our project as its
attention to the ways in which constraints and contingencies at macro
and microlevels shape clinicians’ work with clients experiencing
psychosis as well as to issues implicit in the broader quality of care
within a given program or agency rather than specific components or
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This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
interventions. In spite of the pressing need to improve outcomes for
public sector clients with psychosis, providers in our sample reported
a pronounced lack of prior training and continuing education in
psychosis-specific approaches or best practices. We call for greater
attention to the challenges that front-line providers face in serving
individuals with psychosis, providers’ perspectives on best practices,
and significantly increased investment in strengthening workforce and
organizational capacity.
Keywords: psychosis; schizophrenia; public mental health;
practice-based evidence; clinical intervention
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... Research suggests that mental health staff lack confidence in discussing such experiences with service users, as they believe that they would not be interested, or that it could be dangerous or inappropriate (Coffey & Hewitt, 2008;Harris & Panozzo, 2019). Staff often report feeling helpless and powerless in reducing distress associated with voice hearing (McMullan et al., 2018), indicating that they may benefit from additional training (Jones et al., 2019;McCabe et al., 2016). However, previous findings are limited to relatively small samples of nurses and focus on service users diagnosed with psychosis, thus lacking generalizability. ...
Background Research indicates that clinical staff lack confidence in delivering clinical care for voice hearers. Understanding staff experience is therefore likely to benefit staff training. Objective To explore staff experience of delivering clinical care for voice hearers using qualitative methodology. Method A total of 18 multidisciplinary staff from five acute psychiatric wards participated in brief semi-structured interviews. Interviews were analysed using thematic analysis. Results Six themes were identified. Participants reported Challenges of Understanding Subjective Experience (N = 16) of hearing voices, Empathy for Distress (N = 14) caused by voices, Curiosity about Experience (N = 10) and wish to understand, Anxiety about Clinical Risk (N = 8), especially regarding command hallucinations, Lack of Clinical Confidence (N = 7) in how to respond, and Diversity of Voices (N = 6) experienced by voice hearers. Conclusion Staff have empathy for voice hearers’ distress but feel they lack subjective understanding of what it feels like to hear voices. Lack of understanding, perceived clinical risks, and diversity of voices may be associated with reported lack of clinical confidence. Staff training that promotes greater subjective understanding has the potential to improve therapeutic relationships, clinical confidence, and quality of care. Using simulation technologies and involving people with lived experience in staff training may be ways to improve subjective understanding.
... Jose et al., 2015). Jones et al. (2019) found that service providers emphasized the importance of therapeutic relationships rather than specific treatment techniques; on the other hand, macrolevel factors (including the resources available, plus the increasing mechanization of services with an overreliance on manualized approaches) were seen as barriers to service improvements. The findings were presented as a reminder that, as opposed to the narrow implementation of a specific 24 intervention, there is a need to strengthen the capacity of providers to work more comprehensively across settings . ...
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This research (comprising studies labeled Study I, Study II, and Study III) aimed to eval-uate the long-term outcomes of the family-oriented and need-adapted Open Dialogue approach (OD) in the treatment of first-episode psychosis (FEP). Quantitative and qual-itative data, based on an average follow-up time of 19 years, were derived from the West-ern Lapland research cohort; this included all persons (N=108) who received treatment for FEP over three inclusion periods within the catchment area in which OD was regionally implemented. Study I used case note-based information to analyze specific patterns in the use of mental health services under the OD treatment system (N=65), in the decades following FEP. For Study II, the mortality rates and long-term use of services among the cohort members (N=108) were gathered from national registers. The results were com-pared with a matched comparison group, comprising allFinnish FEP patients with a 19−20 year follow-up whose treatment was initiated outside the catchment area (N=1763). Study III included information gathered via in-depth life-story interviews with 20 members of the cohort. Thematic narrative analysis was used to interpret how the people themselves viewed mental crises and OD as part of their life stories. The re-sults indicated that the practice in the catchment area had followed the principles of OD, even if there was variety in long-term treatment patterns. Compared to other FEP treat-ments, OD was associated with a significantly decreased need for mental health services, and with better maintained work capability at a 19-year follow-up. The standardized mortality ratio was lower under OD, but in both groups, the premature mortality rate was high, and there were no significant differences in suicide rates. The service users themselves emphasized support from their close networks, and also their own actions in the gradual process of surviving, thus reflecting a tendency to associate mental crises with actual life events. The results of this thesis suggested that with gradual develop-mental efforts towards collaborative treatment approaches at the community level, it is possible to help people to maintain their agency and social functioning, accompanied by a decreased need for mental healthcare, decades after FEP. However, due to the obser-vational nature of the study, more research is still needed on the effectiveness and trans-ferability of OD.
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Similar to trends in Europe, approaches to mental illness in colonial America and recorded in early United States history were commonly characterized by incarceration and the removal of individuals from communities. In the mid-20 th century, a major shift began in which treatment was offered in the community with the aim of encouraging individuals to rejoin their communities. In this paper, we will provide a brief history of community mental health services in the United States, and the forces which have influenced its development. We will explore the early antecedents of community-based approaches to care, and then detail certain factors that led to legislative, peer and clinical efforts to create ‘Community Mental Health Centers.’ We will then provide an overview of current community mental health practices and evolving challenges through to the present day, including the development of services which remain focused on recovery as the ultimate goal.
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Background Remission and recovery rates for people with first-episode psychosis (FEP) remain uncertain. Aims To assess pooled prevalence rates of remission and recovery in FEP and to investigate potential moderators. Method We conducted a systematic review and meta-analysis to assess pooled prevalence rates of remission and recovery in FEP in longitudinal studies with more than 1 year of follow-up data, and conducted meta-regression analyses to investigate potential moderators. Results Seventy-nine studies were included representing 19072 patients with FEP. The pooled rate of remission among 12301 individuals with FEP was 58% (60 studies, mean follow-up 5.5 years). Higher remission rates were moderated by studies from more recent years. The pooled prevalence of recovery among 9642 individuals with FEP was 38% (35 studies, mean follow-up 7.2 years). Recovery rates were higher in North America than in other regions. Conclusions Remission and recovery rates in FEP may be more favourable than previously thought. We observed stability of recovery rates after the first 2 years, suggesting that a progressive deteriorating course of illness is not typical. Although remission rates have improved over time recovery rates have not, raising questions about the effectiveness of services in achieving improved recovery.
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Dissemination and implementation science (DI) has evolved as a major research model for children's mental health in response to a long-standing call to integrate science and practice and bridge the elusive research to practice gap. However, to address the complex and urgent needs of the most vulnerable children and families, future directions for DI require a new alignment of ecological theory and public health to provide effective, sustainable, and accessible mental health services. We present core principles of ecological theory to emphasize how contextual factors impact behavior and allow for the reciprocal impact individuals have on the settings they occupy, and an alignment of these principles with a public health model to ensure that services span the prevention to intervention continuum. We provide exemplars from our ongoing work in urban schools and a new direction for research to address the mental health needs of immigrant Latino families. Through these examples we illustrate how DI can expand its reach by embedding within natural settings to build on local capacity and indigenous resources, incorporating the local knowledge necessary to more substantively address long-standing mental health disparities. This paradigm shift for DI, away from an overemphasis on promoting program adoption, calls for fitting interventions within settings that matter most to children's healthy development and for utilizing and strengthening available community resources. In this way, we can meet the challenge of addressing our nation's mental health burden by supporting the needs and values of families and communities within their own unique social ecologies.
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The American populace currently supports the need for providing additional mental health services for adolescents who frequently express anger and mood instability and maybe are at risk for major psychiatric disorders and behavioral problems; Vietnam, Iraqi, and Afghanistan veterans or military personnel still on duty diagnosed with posttraumatic stress disorder, depression, or other similar combat-related disabilities; the approximately 1 million prisoners currently incarcerated primarily because of substance abuse and needing medically related rehabilitative services; and senior citizens who experience dementia and depression and require improved therapeutics. The problems outlined herein are as follows: far too limited monies are being spent for mental health services (5.6% of total US expenditures for health or roughly one fifth of what is consumed for hospital care); effective therapies are often lacking; and there is a shortage of qualified mental health personnel except in upscale urban and suburban areas. Unfortunately, these problems are so immense that, even with enhanced prioritization of our available resources, they are still not entirely solvable. The American public may continue to impart lip service when attempting to respond to our nation's mental health needs or may decide to spend vastly more money for such care. The latter choice may not be forthcoming in the near future for various cultural-societal-clinical-fiscal reasons.
In the past few decades, prevention scientists have developed and tested a range of interventions with demonstrated benefits on child and adolescent cognitive, affective, and behavioral health. These evidence-based interventions offer promise of population-level benefit if accompanied by findings of implementation science to facilitate adoption, widespread implementation, and sustainment. Though there have been notable examples of successful efforts to scale up interventions, more work is needed to optimize benefit. Although the traditional pathway from intervention development and testing to implementation has served the research community well-allowing for a systematic advance of evidence-based interventions that appear ready for implementation-progress has been limited by maintaining the hypothesis that evidence generation must be complete prior to implementation. This sets up the challenging dichotomy between fidelity and adaptation and limits the science of adaptation to findings from randomized trials of adapted interventions. The field can do better. This paper argues for the development of strategies to advance the science of adaptation in the context of implementation that would more comprehensively describe the needed fit between interventions and their settings, and embrace opportunities for ongoing learning about optimal intervention delivery over time. Efforts to build the resulting adaptome (pronounced "adapt-ohm") will include the construction of a common data platform to house systematically captured information about variations in delivery of evidence-based interventions across multiple populations and contexts, and provide feedback to intervention developers, as well as the implementation research and practice communities. Finally, the article identifies next steps to jumpstart adaptome data platform development.
This book explores the moral lives of mental health clinicians serving the most marginalized individuals in the US healthcare system. Drawing on years of fieldwork in a community psychiatry outreach team, Brodwin traces the ethical dilemmas and everyday struggles of front line providers. On the street, in staff room debates, or in private confessions, these psychiatrists and social workers confront ongoing challenges to their self-image as competent and compassionate advocates. At times they openly question the coercion and forced-dependency built into the current system of care. At other times they justify their use of extreme power in the face of loud opposition from clients. This in-depth study exposes the fault lines in today's community psychiatry. It shows how people working deep inside the system struggle to maintain their ideals and manage a chronic sense of futility. Their commentaries about the obligatory and the forbidden also suggest ways to bridge formal bioethics and the realities of mental health practice. The experiences of these clinicians pose a single overarching question: how should we bear responsibility for the most vulnerable among us?.
In 2003 the Bush Administration’s New Freedom Commission asked mental health service providers to begin promoting "recovery" rather than churning out long-term, "chronic" mental health service users. Recovery’s Edge sends us to urban America to view the inner workings of a mental health clinic run, in part, by people who are themselves "in recovery" from mental illness. In this provocative narrative, Neely Myers sweeps us up in her own journey through three years of ethnographic research at this unusual site, providing a nuanced account of different approaches to mental health care. Recovery’s Edge critically examines the high bar we set for people in recovery through intimate stories of people struggling to find meaningful work, satisfying relationships, and independent living.
Efforts to identify empirically supported treatments (ESTs) for youth's mental health problems are valuable, but the descriptor empirically supported does not guarantee that a treatment will work well in everyday clinical use. The voltage drop often seen when ESTs move from efficacy studies to clinical practice contexts may reflect limited exposure to real-world conditions during development and testing. One result may be interventions that are focused more narrowly and are more linear than the clinical practice they are designed to enhance. In this article, we suggest three strategies for building and refining ESTs that are robust for real-world application: (a) designing interventions to fit the contexts of youth treatment, (b) structuring interventions that can be tailored to fit individual youth characteristics, and (c) building programs for nontraditional intervention contexts. In addition, we describe how to develop interventions that are ready for practical implementation: the deployment-focused model.