The International Journal of Psychosocial Rehabilitation

Shortfalls of Treatment for Patients with Schizophrenia:
  Unmet Needs, Obstacles to Recovery

Eris F. Perese, APRN-PMH
Clinical Associate Professor

Yow-Wu Bill Wu, PhD
Associate Professor

University at Buffalo, School of Nursing
3435 Main Street, Buffalo, NY 14127



Citation:
Perese EF & Wu YB (2010). Shortfalls of Treatment for Patients with Schizophrenia:  Unmet
Needs, Obstacles to Recovery
. International Journal of Psychosocial Rehabilitation. Vol 14(2). 43-56  




Abstract
Background:  Recovery-oriented programs such as Assertive Community Treatment (ACT) achieve improvement in many areas; however, impaired functioning is often unchanged and results in unmet needs, obstacles to patients’ goal of recovery.  Objectives:  Determine if there is change in participants’ unmet needs after 12 months of ACT.  Study design is descriptive and longitudinal.  Results: On admission, 20 to 30% of participants identified unmet basic survival needs--food, clothing, housing, finances, and medical/dental care; 32-52% for friends, transportation, and meaning to life; 77.5% for group membership; and 95% for a role.  At 12 months, fewer patients had unmet survival needs. Personal safety need was unmet for 27.5%.  There was no change in unmet group membership, meaning to life, and role needs.  Fewer participants reported unmet needs for friends identifying ACT team as friends.  Conclusion: ACT is effective for basic survival needs and health care needs but not for social connectedness needs. .


Key words: Assertive Community Treatment (ACT), schizophrenia, recovery, unmet needs

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.


Introduction
For a long time, the future for patients with schizophrenia was a life longsentence to a chronic illness with no hope of recovery (Spaniel, Gagne & Koehler, 2003). Treatment goals were compliance with medications, reduction of hospital admissions, and adjustment to a chronic illness (Marder, 2005). By the 1990’s, patients and families were repudiating those goals (Deegan, 1996; Ramon, Healy & Renouf, 2007) and advocating for recovery, the same treatment goal held for patients with medical illnesses (Ahern & Fisher, 2001). Now, recovery is accepted as the desired outcome of psychiatric treatment (Ramon et al. 2007). 

The goals of recovery are for patients to return to a meaningful social role, develop relationships, re-claim a sense of self identity, and become participating members of the community (Ahern & Fisher, 2001; Lysaker & Buck, 2006).  The process of recovery involves changes that patients make—keeping hope alive; accepting the need to be actively involved in promoting healing; developing self-confidence, courage and responsibility; finding a new meaning or purpose in life; and rebuilding social connectedness by taking on new roles in relationships, work, and the community (Jacobson & Greenley, 2001).   The process of recovery also involves factors external to the patient such as mental health care providers’ attitudes of compassion, respect, and belief in patients’ ability to achieve healing and the provision of recovery-oriented services. Recovery-oriented services include management of patients’ symptoms and distress, meeting patients’ needs, promoting rehabilitation, and protecting patients’ rights and personal safety (Anthony, 1993; Jacobson & Greenley, 2001). 

Comprehensive treatment programs such as Assertive Community Treatment (ACT) that promote the goal of recovery have been found to reduce the hallucinations, delusions, and depression experienced by patients with schizophrenia but are less effective in reducing the problems related to impairment of functioning—deficits in self-care, academic difficulties, inability to work, problems with social interactions, and inability to develop and maintain intimate relationships (McGorry, 2005; Hyman & Insel, 2007).  Patients’ residual impaired functioning often leads to unmet needs with greater impairment of functioning linked with higher rates of unmet needs (Becker, Leese, Krumm, Ruggeiri, Vazquez-Barquero & the Epsilon Study Group, 2005).  

The nursing theory of adaptation, Modeling and Role-modeling (M & RM), (Erickson, Tomlin & Swain, 1983) that guides this study proposes that patients meet their needs through attachment to others; to community institutions such as those that provide health care; and to valued causes and beliefs.  When needs are met, patients develop internal resources such as hope and a sense of self-competence that enable them to cope adaptively with the challenges and stressors associated with their illnesses (Bray, 2005).  When needs are unmet, or only partially met, patients’ potential to adapt is diminished and they may use maladaptive coping or require more health care services and compensatory interventions (Erickson, 2006).  

The needs of all humans include basic survival needs (food, clothing, housing, transportation, financial resources, and personal safety); health care needs (mental health care, physical health care including dental care); and social-connectedness needs (friends, a group to belong to, a role in life, and a meaning or purpose in life) (Hansell, 1976).  Although needs are often considered to be hierarchical (Maslow, 1970), Hansell (1976) believes that needs are cantilevered rather than hierarchical with each need supporting all other needs. One unmet need adversely affects all needs, ability to adapt to stressors, and achievement of well-being.

Unmet needs among patients with severe mental illness such as schizophrenia
Basic survival needs: food, clothing, housing, transportation, finances, and personal safety.
Among patients with severe mental illnesses such as
schizophrenia, needs for food and clothing are not often reported as unmet (Becker, et al. 2005).  For example, only 7% of patients with severe mental illness reported an unmet need for food in the study of Grinshpoon and Ponizovsky (2007).  Patients may live at home or in supervised housing where food and clothing may be provided for them and some may obtain food and clothing from soup kitchens or drop-in centers.  Ashcraft, Anthony and Martin (2008) believe that recovery begins with appropriate housing.  The need for appropriate housing was found to be unmet for 46% of patients with schizophrenia (Kovess et al. 2005). Similarly, transportation is a frequently occurring unmet need (Grinshpoon & Ponizovsky, 2007).  Financial resources are often not adequate to live on (Ware, Hopper, Tugenberg, Dickey & fisher, 2007).  Beebe (2002) reported that 27% of patients with schizophrenia living in the community identified financial problems, lack of sufficient funds to get by.  For over 30 years, researchers have described the unmet need of patients with schizophrenia for personal safety, safety from abuse and victimization (Krauss & Slavinsky, 1982; Lehman & Linn, 1984; Perese, 1997) with Teplin, McClelland, Abram, and Weiner (2005) reporting victimization rates of 25% to 38%, 12 times the rate for the general population.

Health care needs.
 
In comparison to the general population, patients with schizophrenia have more health problems and a 20% shorter life span (Salokangas, 2007; Leucht, Henderson, Maj & Sartorius, 2008).  About 50% have at least one medical condition such as diabetes, obesity, chronic obstructive pulmonary disease, cardiovascular disease, or HIV infection (Connolly & Kelly, 2005; Baki, Meszaros, Stutynski, Dimmock, Leontieva, et al. 2009).  They also have more dental and eye problems than the general population (Dixon, Postrado, Delahanty, Fischer & Lehman, 1999).  However, despite this increased vulnerability, they are less likely to receive preventive care and needed dental care than the general population (Salokangas, 2007; McCreadie, Stevens, Henderson, Hall, McCaul, et al. 2009).

Social- connectedness needs.
Social connectedness, the reciprocal relationships that individuals have with others, provides support and a sense of belonging and is associated with health and well-being (Ware et al. 2007; Social Connectedness: Social Report 2008).  Social connectedness develops from the roles that individuals play in life as partners, friends, teammates, workers, and participants in community and spiritual activities.  Among patients with schizophrenia, social connectedness has been found to be a strong predictor of positive response to treatment (Harvey, Jeffreys, McNaught et al. 2007) and patients believe that social connectedness is a key factor in promoting recovery (Happell, 2008). 

Friends.
 
Many authors have described the lack of friends among patients with severe mental illness (Bellack & Muesser, 1986; Torrey, 1988).  For example, among patients with severe mental illness who belonged to the National Alliance for the Mentally Ill (NAMI), 62% identified an unmet need for a friend (Perese, 1997).  In describing the effect of lack of friendship among patients with severe mental illness, Wheaton (1997) says that it is the sense of isolation, the loneliness, and the lack of someone to talk with that is most troublesome. More than half of patients with severe mental illness describe problems with loneliness (Clinton, Lunney, Edwards, Weir & Barr, 1998) in comparison to one-third of the general population (Lauder, Sharkey & Mummery, 2004). Recently, Beebe (2010) reported that 42% of patients with schizophrenia living in the community identified loneliness as a problem.

Role.
Role in life is often associated with employment, filling the role of a worker and co-worker (Buizza, Schulze, Bertocchi, Rossi, Ghilardi, et al. 2007). Unfortunately, among patients with schizophrenia, unemployment is high with a rate of 72.9% reported by Rosenheck, Leslie, Keefe, MeEvoy, Swartz, et al. (2006).   Patients with severe mental illness believe that work enables them to have pride in themselves, to develop coping strategies for managing psychotic symptoms so that they can work, and to re-establish a sense of identity.  They believe that work promotes recovery (Dunn, Wesiorski, & Rogers, 2008).

Meaning or purpose to life.
A sense of meaning or purpose to life encompasses both spirituality and religiousness (Mohr & Huguelet, 2004; Huguelet, Mohr, Borras, Gillieron, C. & Brandt, P-Y., 2006) and is associated with a sense of well-being (Stolovy, Lev-Wiesel, Doron & Gelkopf, 2009). Patients with schizophrenia describe religion as being an important part of their daily life (Huguelet et al. 2006); and, they often use religion to cope with the symptoms of their illness and with daily problems (Tepper, Rogers, Coleman et al. 2001).  The role that a sense of meaning or purpose plays in recovery is related to its ability to facilitate a reconstruction of a sense of self-identity and to build social connectedness (Roe & Chopra, 2003; Mohr & Huguelet, 2004).

Although meeting their needs has been identified by patients with severe mental illness as the first step toward recovery (Recovery, 2003), there is little information about need satisfaction as an outcome of recovery-oriented programs such as ACT.  Cadena (2006) suggests that meeting needs should be a core component of treatment programs and that it should be evaluated as an outcome of treatment.

Purpose
The purpose of this study was to determine if participation in Assertive Community Treatment (ACT) by patients with schizophrenia for one year was associated with a decrease in specific unmet needs.   

Method
The research was guided by two questions:
1.  What percentage of patients with schizophrenia on admission to ACT had specific unmet needs—food, clothing, transportation, housing, financial resources, medical care, dental care, a friend nearby, a friend talk to, a friend who could help, a group to belong to, a role in life, and, a meaning/purpose in life?
2.  Was there a difference in percentage of patients with specific unmet needs between admission to ACT and after 12 months of ACT?

Setting and sample
Setting. The setting was an ACT program operated by a not-for-profit Behavioral Health Services Organization in an urban area of Western New York.  ACT is distinguished from other comprehensive programs for patients with severe mental illness by several features.  ACT uses a team approach.  The team is multidisciplinary and includes psychiatrists, social workers, nurses, rehabilitation specialists, case managers, and peer counselors. It serves as the primary provider of all patient services and, because of this feature, has the ability to rapidly provide services—food, clothing, housing, medical care, financial resources, and legal aid-- often within hours of the patient being admitted to ACT.  It provides services in community settings such as in the patients’ homes, group homes, or hotel rooms.  It is pro-active using outreach to assist patients to participate in treatment, live independently, and move toward recovery (Assertive Community Treatment Association, 2009).  

ACT is considered to be the gold standard of care for patients with schizophrenia (Kovess, de Almeida Jose, Carta, Dubuis, Lacalmontie, et al. 2005; McGorry, 2005).  There is strong evidence that ACT reduces hospitalizations and length of stay in hospital (Barry, Zeber, J., Zeber, J.E., Blow, & Valenstein, 2002; van Os, 2009) and improves psychiatric symptoms (Barry et al. 2002), functioning (Dixon, 2000), housing stability (Phillips, Burns, Edgar, Mueser, Linkins, et al. 2001), and quality of life (McGrew, Bond, Dietzen, McKasson & Miller, 1995). There is weaker support for ACT’s ability to improve social adjustment and vocational functioning (Burns, 2001).  Some researchers have questioned the compatibility of ACT and recovery suggesting that fidelity to certain ACT principles—team approach, outreach, and high intensity of services—may interfere with patients’ choices (Drake & Deegan, 2007). However, others believe that ACT can incorporate principles of recovery—consumer choice, hope, respect, compassion, and patience—and that ACT is well suited to the recovery model (Salyers & Tsemberis, 2007).  

Sample.
 
After obtaining approval from the University at Buffalo’s Institutional Review Board and the agency’s clinical director, the 71 patients in the ACT program were offered the opportunity to join the study. Fifty-six (79%) agreed to participate and signed consent forms.  As reported previously, there was no significant difference in age, race, marital status, living situation, employment, dangerousness, arrests/incarcerations, hospital readmissions, and functioning between patients who agreed to participate and those who refused (Perese, Wu & Ram, 2004). The initial interview was done soon after admission to ACT, within days if possible; but occasionally it would take longer to arrange a time when the patient would be available to be interviewed; e.g., two to three weeks after admission. In individual interviews, the senior author assessed the participants with the Buffalo Client Assessment Inventory (BCAI) that was developed by the authors.  The BCAI includes structured questions and 10 brief self-report instruments including ones that measure specific unmet needs. At 12 months, participants were interviewed again using the same instruments.

The results of the study of the 56 participants were presented in an article that described outcomes such as psychiatric symptoms, distress, functioning, dangerousness, and stability of housing (Perese et al. 2004).   Data obtained about specific unmet needs and the changes in specific unmet needs after treatment were not presented.  Among the 56 participants, 40 had been given a diagnosis of schizophrenia by a psychiatrist on admission to ACT.  Data related to the unmet specific needs of these 40 participants with schizophrenia is presented in this study.

Variable: specific needs
The specific needs measured in this study are those that Hansell’s (1976) considered to be essential for survival.  They have been operationalized as need for: food, clothing, transportation, housing, financial resources, medical care, dental care, friends (a friend nearby, a friend to talk to, and a friend who could help), group membership, a role, meaning/purpose in life, and personal safety.  These needs have also been identified by patients with severe mental illness as needs that must be met in the first step toward recovery.

Study design
This was a descriptive, longitudinal study of data obtained as part of a larger, comparative study (Perese et al. 2004).  Data about specific unmet needs had been obtained but not examined nor reported .

Instrumentation
Record review was used to obtain data on demographic characteristics, employment status, housing, psychiatric diagnosis, danger to self or others, hospital admissions during year prior to ACT, and victimization during year in ACT.  The Social Support Index (SSI), (Bell, LeRoy & Stephenson, 1982), was used to measure unmet needs for a friend who is nearby, a friend who can be relied on to provide help, and a friend who you can talk to about problems; for a group membership; and for a sense of meaning or purpose in life.  The response choices were yes, needs were reported as met, or no, not met.  The Meeting Basic Needs Scale  (Ellis, Wilson & Foster, 1984) that has a  score range of 7-28 with higher score indicating more unmet needs was used to measure the need for: food, clothing, transportation, housing, financial resources, medical care, and dental care.  Needs that were reported as always met or met most of the time were considered to be met.  Needs that were reported as sometimes met or not at all were considered to be unmet.    The need for a role in life was determined to be met if patients responded that they were employed, or in school. The need for personal safety was determined to be met if review of the record revealed no history of victimization during the year in ACT. 

Results
Demographic characteristics
The participants were predominantly male and in the 30 to 49 year age group with more participants in the African American group than other groups combined. Nearly half had not completed high school.   More than three-fourths had never married and the others were divorced, widowed or separated. Nearly all, 95%, were unemployed or totally disabled.  The two participants (5%) who responded that they were working were not working in competitive or sheltered situations.  They said that they earned their living by doing odd jobs.  Participants were more likely to be living in stable housing (house, apartment, room, group home, board-and-care) than in unstable housing (homeless shelters, streets, motel, or with a friend). Nearly all (91%) had been hospitalized during the year before admission to ACT with one-fourth hospitalized more than three times. One-fourth of the participants had engaged in behavior that was dangerous to others.  All had a Global Assessment of Functioning (GAF) score below 40, a score that indicates severe distress and impairment of functioning. (See Table 1.)
 

Table 1.  Demographic, clinical and community adaptation characteristics on admission to ACT (n=40)

Gender
     Male          
     Female                                                  Age
     18.29
    30-49                                                        
     50 and >                                               Race
     Black                                                 
     White                                                 
     Hispanic                                               
Marital status
     Single                                                   
     Divorced, widowed, separated              
Education
     Less than high school                          
     High school                                          
     Some college                                          
     College degree                                        
     (Missing data for 2)
Employment/school                                    
     Employed                         
     Unemployed                                         
      Disabled for work                                  
Living situation
      Stable housing (apartment, room,         
      board and care)
      Unstable housing ( homeless,                
      streets, shelters, with friends,
      motel/hotel)
GAF
20
25
30
35
                
Admitted to psychiatric hospital
during year prior to ACT
    0 hospitalizations                                       
    1-3 hospitalizations                                    
    More than 3 hospitalizations                     
                                                                  
 n   (%)
32 (80) 
  8 (20)
 
 3 (7.5)
29 (72.5)
  8 (20)
 
25 (62.5
13 (32.5)
  2 (5)
 
31 (77.5)
  9 (22.5)
 
18 (47.4)
16 (42.1)
  3 (7.9)
  1 (2.6)
 

 
2 (5)

12 (30)
26 (65)
 
28 (70)
 
12 (30)
 
 
 
  4 (10.0)
  8 (20.0)
23 (57.5)
  5 (12.5)
 
 
 
 4 (10)
26 (65)
10 (25)
Global Assessment of Functioning (GAF): 50-41 indicates serious distress and dysfunction;
40-31 indicates severe distress and dysfunction, 30-21 indicates inability to function in most areas;
 and 20-11 indicates dangerousness to self or others (Rosse & Deutsch, 2000).

Unmet needs at admission to ACT and after 12 months of ACT
The baseline assessment of specific needs was done as soon after admission to ACT as possible, usually within days of admission.  Within basic needs, 17.5% to 40% of participants reported unmet needs with unmet needs for housing (30%) and transportation (40%) greater than for food (22.5%), finances (20%), and clothing (17.5%). Within health care needs, the unmet need for dental care (27.5%) was greater than that for medical care (17.5%).  Within social connectedness needs, a greater number of participants identified unmet needs for a role in life (95%), a group to belong to (75%), a friend who could help (62.5%), a friend to talk to (48.7%), and a meaning or purpose in life (42.5%) than for a friend nearby (37.5%).  (See Table 2.).

Only 29 of the 40 participants were available to be interviewed at 12 months. One subject had died, four had been admitted to a long-term psychiatric institution, one was admitted to a nursing home, two were incarcerated, two had been discharged for not participating, and one was still with ACT but was not available to be interviewed. 

The available data suggest that there was a decrease in the percent of patients with unmet needs for housing (5.0%), financial resources (7.5%), and medical care (7.5%).  Although there was no decrease in the percent of patients with an unmet need for a friend near by, there was a decrease in unmet needs for a friend who could help and a friend to talk to.  (In responding to these questions, participants often identified ACT team members, especially peer counselors, as friends who could help or friends they could talk to.) On review of the participants’ records at 12 months,  it was found that 11 (27.5%) of the participants had reported incidences of victimization such as: beaten in a fight, a stab wound, assaults, accosted for money, sexual molestation, mugged and purse taken, and having winter coat stolen during the year that they were in ACT.  However, there was no systematic method of collecting data on victimization. Counselors recorded information about victimization when patients reported it.  (See Table 2.)
  

Table 2.  Percentage of patients with unmet needs on admission to ACT and at 12 months after admission

Need

Unmet needs at admission to ACT (n=40)

Unmet needs at 12 months

(n=29)

Food

22.5

10.0

Clothing

17.5

17.5

Transportation

40.0

29.7

Housing

 

30.0

  5.0

Financial resources

 

20.0

  7.5

 

Medical care

 

17.5

  7.5

 

Dental care

27.5

22.5

 

A friend near by

37.5

34.5

A friend who could help

62.5

30.0*

 

A friend to talk to

48.7

37.5*

 

A group to belong to

75.0

72.4

A sense of meaning to life

 

42.5                    

45.0

 

A role in life

(employment, married, student)

95.0

95.0

Personal safety

not available

27.5%

* Patients frequently identified members of the ACT team as a friend who could help or a friend to talk to.

 Discussion
 Limitations.  Generalizability of the findings of this study is limited by the small sample size and the fact that the sample consisted of volunteers.  The researchers had no control over the selection of the sample.  A further limitation is the high rate of attrition.  Only 29 of the 40 participants with schizophrenia were available to be interviewed at 12 months. Because four participants had been readmitted to an inpatient psychiatric unit, two were in jail, and two were discharged for non-participation in ACT, it is likely that the eight participants no longer in the study had greater severity of their illnesses or were less responsive to ACT than the participants who remained in the study.  Another limitation is that there was insufficient power to detect differences from admission to 12 month assessment.  Despite these serious limitations, the data are presented in order to add to the available information about the unmet needs of patients with schizophrenia living in the community and to the information about the outcomes of ACT.  

In response to research question one, the percent of patients with unmet needs at the time of admission to ACT differed according to the category of need and also by specific needs within a category.  For example, among basic needs--food, clothing, finances, and housing-- unmet needs were reported by 17% to 30% of the participants.  This relatively low rate of unmet needs may be due to ACT’s ability to provide patients with food, clothing, small amounts of money or vouchers, and housing very quickly, often within hours of being admitted to ACT.  The basic need for transportation was reported as unmet by 40% of the participants; and, because participants often added the comment that they walked everywhere, it is likely that the unmet need was higher. One explanation for the high unmet need for transportation is that more time is required for ACT to obtain bus passes than the time required to meet other basic needs.   Within health care, medical care was reported as unmet by only 17.5% of the participants but dental care was unmet for 27.5%%.  Because of an agreement with a primary care group, ACT was able to arrange for medical care very quickly but it took much longer to arrange for dental care.  This finding supports previous reports of lack of dental care for patients with schizophrenia.  


Unmet needs were highest in the category of social connectedness—meaning to life, friends, group membership, and role in life.  More than 40% reported an unmet need for a sense of meaning or purpose in their lives at the time of the interview. Often they would add comments about what they had once wanted to do in life or that once they had belonged to a church.  Conversely, the finding that 60% had a sense of meaning or purpose supports the reports of the importance of religion or spirituality for patients with schizophrenia.  In relation to the unmet need for friends, more participants had a friend who lived near by than had friends whom they could talk to or ask for help.  However, participants often added that the friend nearby was the person who served them coffee in the coffee shop.  The unmet need for a friend who could be depended on for help was highest, 62.5% of the participants.  Although the literature has reported that patients with schizophrenia often have small social networks and lack friends, this study identifies the high rate of the specific unmet need for a friend who could provide help.   That three-fourths (75%) of the participants identified an unmet need for a group to belong to, to do things with, or just to hang out with poignantly depicts their lack of connection to social or community activities.   Almost all of the participants had an unmet need for a role in life as defined by this study— employed or in school.  However, it is likely that many of the participants fulfilled roles not defined in this study—partners, helpers, peace-makers, mentors, and others.  For example, Ware et al. (2007, p 472) suggest that role in life should include “living a worthy life”.  Thus, on admission to ACT, many of the participants had unmet needs that were potential obstacles to the goals of recovery--to return or develop a meaningful social role, to build relationships, to re-claim a sense of self identity, and to become participating members of the community Research question two asked if there was a difference in the percentage of participants with specific unmet needs between admission to ACT and after 12 months of ACT.  The available data suggest that there was a marked decrease in the percent of patients with unmet needs for housing, finances, and medical care. It seems that, over time, ACT was able to help patients to find appropriate housing, secure financial resources, and receive on-going medical care.   Although there was only a slight decrease in the percent of patients with an unmet need for a friend near- by, there was a greater decrease in unmet needs for a friend who could help and a friend to talk to.  However, participants often identified ACT team members, especially peer counselors, as the friends who could help or friends they could talk to. Thus, it does not appear that the participants built new friendships outside of the ACT team.  There was a slight decrease in the unmet need for group membership and a slight increase in the unmet need for a sense of meaning or purpose in life.  There was no change in role in life. Overall, the data suggest that for social-connectedness unmet needs—friends, group membership, meaning to life, and a role in life--there was little or no response after 12 months of ACT.    This finding supports previous reports of ACT’s weaker ability to improve social adjustment and vocational functioning. 

The results of this study suggest that recovery-oriented ACT programs for patients with schizophrenia should add interventions that target unmet needs non-response to ACT.  For example, ACT could add support groups, discussion groups, or other socializing opportunities such as coffee clubs and could link patients with self-help groups such as psychosocial clubs or ready made friends such as those provided by Compeer or Befriending organizations to address the unmet needs for friends and group membership.  The unmet need for personal safety could be addressed by the ACT team assessing for bullying, harassment, victimization, and exploitation at each patient visit and by providing interventions such as crime prevention programs--similar to programs for acquaintance rape and family violence-- and teaching “street smarts” to reduce victimization.  The unmet need for a role in life such as employment is challenging to address. The causes are multifaceted—lack of entry level jobs, fear of losing financial entitlements and health coverage, deficits of educational preparation, lack of prior work experience, and limited social skills.  In this study, because the ACT program was already promoting vocational rehabilitation and supported employment, it seems likely that more than 12 months are required to see a change in employment. Finally ACT programs can seek the help of spiritual leaders and parish nurses to create bridges to help patients meet their needs for meaning to life.

After the study was completed, the researchers shared the findings with the ACT team emphasizing that unmet social connectedness needs appeared to be non-responsive to treatment and that there was a need to address the unmet need for personal safety.  In response, the ACT team developed discussion groups and coffee clubs for the patients that were well received by the patients.  
Conclusion
Some of the unmet needs of patients with schizophrenia, such as the unmet need for social connectedness, are obvious obstacles to the goals of recovery--patients returning to or achieving meaningful social roles, relationships, and membership in their communities. However, because needs are cantilevered, each essential to the other and to overall functioning and well-being, every unmet need is a deterrent to recovery.  For example, unmet needs for money, transportation, and desirable housing affect the need for social connectedness and thus for recovery.  This study found ACT to be effective in meeting basic survival needs, with the exception of the need for personal safety, and health care needs; but, ACT was less effective in meeting social connectedness needs.   

 



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