Psychosocial Treatment Interventions for People with
Severe Mental Illness in a Community
Margareta Östman, Ph.D.
Professor, Department of Health and Welfare Studies
Faculty of Health and Society, Malmö University, Sweden. E-mail: firstname.lastname@example.org
Tommy Björkman, Ph.D. (deceased 2012)
Department of Health
Care and Society, Faculty of Medicine, Lund University, Sweden
Östman M & Björkman T, (2015) Psychosocial Treatment Interventions for People with Severe Mental Illness
in a Community. International Journal of Psychosocial Rehabilitation. Vol 19(2) 96-105
Jan Waldenströms gata 25
214 28 Malmö
surveyed 80 people with severe mental illness living in the community
in Malmö, Sweden in order to determine their views on the psychosocial
interventions many had received from psychiatric services. No
measurable differences in background aspects, including self-stated
diagnosis and quality of life, were found between those who received
interventions and those who did not. However, younger people were more
often given cognitive behavior therapy, while individuals living in
their own apartments tended to be the recipients of cognitive behavior
therapy, assertive community treatment programs, and family
interventions. Out findings showed that psychiatric services not only
select people with a high quality of life for psychosocial
interventions, but our results indicate that such interventions are
generally directed toward people whose severe mental illness lies
outside the spectrum schizophrenia disorders.
Keywords: severe mental illness (SMI), psychosocial interventions, quality of life, Sweden
and clinical evidence has often reported extensive social dysfunction
in people with schizophrenia and severe mental illness (SMI) (Mueser et
al., 1991; Ganev, 2000; Wiersma et al., 2000; Mubarak et al.; 2003;
Lambert et al.; 2006; Goreishizadeh et al., 2012). People with SMI have
significant impairments in areas of occupational activity, daily
living, intimate relationships, and the use of specialist mental health
services, regardless of evidence-based pharmacological treatment
(Wheeler, 2007). The recovery approach to service delivery for people
with schizophrenia and other SMIs comprises not only the treatment of
the illness, but extends to addressing such fulfil basic needs as
gainful employment and household management. The goal is to enable
individuals to lead meaningful lives (Mental Health Commission, 1998).
The optimal treatment for schizophrenia and SMI according to current
clinical practice focuses on both alleviating symptoms and functional
recovery using a range of pharmacological, psychosocial, and
psychological interventions (Lehman et al., 2004; Dixon et al., 2010).
Psychosocial treatments have been shown to enhance functioning beyond
the improvements resulting from medication alone (Addington et al.,
2010). This combination of psychosocial interventions and medications
not only provides more health gain to patients, but also reduces
hospitalization costs (Phanthunane et al., 2011)
research has been done on the views of people with SMI living in the
community with regard to the different psychosocial interventions
provided to them by psychiatric services. As part of a larger study
investigating the provision of formal and informal care, we will
examine from the point of view of such people the relationship between
background aspects and quality of life (QOL), and the provision of
different psychosocial treatment interventions in an outpatient setting.
background of this study is a survey of support and treatment
facilities for people with SMI who live in a Swedish community
(Nordström et al., 2009; Östman & Björkman 2014). In 2008,
psychiatric and social services staff members in two of the ten
districts in the municipality of Malmö, the third largest city in
Sweden, were asked to make an inventory of the people with SMI whom
they served. The object was to learn what these patients thought their
treatment needs were, and how they utilized and experienced the
services available to them.
the inclusion criteria, an individual had to have an SMI and reside in
one of the two districts in Malmö where the study was conducted. The
districts had populations of 18,000 and 32,000 inhabitants,
respectively. We defined SMI in accordance with the World Health
Organization (WHO) as a diagnosis of psychiatric illness of more than
two years duration that also involved a disability in functioning (WHO,
2001). Participants had to be over 18 years of age and unable to manage
their everyday lives without help from others in consequence of a
functional psychiatric disability. The assistance needed could be
either permanent or recurring, but had to have persisted for at least
six months at the time of the investigation.
The clinical staff
compiling the inventory identified 153 people who met the inclusion
criteria, of whom 43 declined to take part in the study and another 30
could not be contacted. Thus, 80 people agreed to participate. (No
information was available on those who could not be reached or would
not participate.) The mean age of the participants was 47 years (range
19 to 81). Most were men (72%), single (87%), and lived in their own
house or own apartment, or in a rented home (74%). Sixty percent
self-reported a diagnosis of schizophrenia and 84% were on
medication prescribed by psychiatric services. The participants’ first
contact with psychiatric services took place on average 18 years
previously (range 1 to 53 years). Almost half (43%) were engaged in
everyday occupations. Background characteristics and living conditions
are shown in Table 1.
Table 1. Background
characteristics of the participants (n = 80)
Age (mean, range) 47, 19-81
Gender (n = 79)
Marital status (n = 77)
Children in the family
Own house or apartment,
or rented accommodation
Schizophrenia or other
Other, including diagnosis
from psychiatric services
about the user’s life circumstances and the support received from
formal and informal caregivers was gathered at a personal interview. A
questionnaire was employed based on an instrument used in a Swedish
survey investigating the life circumstances of people with a
psychiatric disability (Nordström et al., 2009). The instrument
contained 76 items organized in four domains: socio-demographic data
and present living situation; support from formal organizations;
support from informal organizations; and health and illnesses.
order to determine whether a participant received psychosocial
treatment interventions, we developed a questionnaire based on both the
Schizophrenia Patient Outcomes Research Team (PORT) study (Lehman &
Steinwachs, 1998) and the Swedish National Board of Health and Welfare
recommendations of evidence-based psychosocial interventions for people
with schizophrenia (2011). The questionnaire asked participants to
respond with a “yes” or “no” if they had previously been given any
information on family education, social skills training, cognitive
behaviour therapy, assertive community treatment, or work
rehabilitation/supported employment. They were also asked whether they
had participated in any of the above psychosocial interventions.
Manchester Short Assessment of Quality of Life (MANSA) was used to
measure overall QOL (Priebe et al., 1999). It is administered as a
structured interview containing 16 items (4 objective and 12
subjective), and includes an individual’s subjective rating of general
life satisfaction and satisfaction with specific domains of QOL. These
include work, finances, social relations, leisure, living situation and
the individual one lives with, security, family relations, sexual
relations, and physical and psychological health. Ratings are made on a
scale from one (worst) to seven (best), allowing an overall subjective
QOL score to be calculated. The MANSA has been translated into Swedish
and found to be psychometrically sound (Björkman & Svensson, 2005).
total mean values were used to assess QOL. Items measuring categorical
variables were dichotomized. Experiences of psychosocial interventions
were analysed individually and divided into subgroups: a) no
interventions, b) one or two, c) more than two. Statistical differences
between groups were investigated using the chi-square test for
categorical values and one-way analysis for continuous variables. The
probability level required to demonstrate significance was set at not
above 0.05. Statistical analyses were conducted using SPSS software.
persons eligible to participate in the investigation were provided with
oral and written information about the study through a contact person
known to them. Those who agreed to take part gave their written
informed consent after the study had been fully explained to them and
prior to being interviewed. Since people with SMI living in a community
are generally known to be hard to reach, they constitute a neglected
group in research studies, which may justify analysis of the data
despite the relatively high number of drop-outs.
Our data was
obtained directly from the individual suffering from SMI, supported by
a contact person from psychiatric care or social services (often a
social worker or a nurse chosen by the interviewee). Each participant
selected the time and place for the questionnaire to be administered.
Those conducting the interviews had considerable experience in caring
for people with SMI. The researcher who analysed the data had no
affiliation with any of the service providers who supported the
participants. Data gathering was done in accordance with the Helsinki
Declaration. Permission for the study was obtained from the Regional
Ethics Committee in Lund (Dnr 238/2007).
Treatment and support
of the participants had received care of some kind from psychiatric
services, the majority as out-patients. The most common support
provided was medication (84%), followed by advice, psychosocial
interventions, and psychotherapy. Forty-eight per cent had a contact
pattern of once a week; 34% were seen monthly. Most were treated by a
psychiatrist (67%) or a nurse (53%). Of the patients who came in
contact with psychiatric services, 77% said they were satisfied with
the support they received. The 23% who were dissatisfied wanted more
effective medications, additional psychotherapy, or both.
Information provided about psychosocial treatment interventions
than half of the participants acknowledged that they had been informed
of at least one of the five psychosocial interventions we investigated.
Of these, 60% had been offered cognitive behavior therapy, 57%
assertive community treatment, 53% work rehabilitation, 34% social
skills training, and 18% family interventions.
of 80 participants (71%) said that they received psychosocial treatment
interventions at some time: 21 had one intervention (26%), 23 had two
(28%), and 19 had more than two (24%).
Of the 141 interventions
received by people with SMI, 43 were cognitive behavior therapy, 38
assertive community treatment programs, 30 work rehabilitation
assistance, 22 social skills training, and only 8 family interventions.
participants who received some psychosocial intervention with those who
received none, we found no significant differences in any of the
background variables measured, including diagnosis or QOL. Additional
analyses investigating differences between participants subjected to
three or more psychosocial interventions (n = 19) and those subjected
to no interventions (n = 15) found only one significant difference:
participants who had received three or more interventions were
generally in independent living, chi-square = 4.23; p = .040.
Comparisons of psychosocial interventions and background variables
shown in Table 2, we found few significant differences between the
psychosocial intervention given and background variables. People who
received cognitive behavior therapy tended to be of younger age (43.4
vs. 50.8) (t = ¬-2.23; p = .008); they generally lived in their own
apartments, (chi-square = 11,36; p = .001), and showed a higher MANSA
mean score (4.9 vs. 4.4) (t = -2,2: p = .031). Those who experienced
assertive community treatment programs more often lived in their own
apartments (chi-square = 5,05; p=.025); the same was true of people who
were given family interventions (chi-square = 3.88; p = .049).
MANSA QOL scale correlated to psychosocial factors
assessing satisfaction with life domains (Table 3), we found that
living accommodations, personal security, those people with whom one
lives, and family relationships were the areas participants rated as
their sources of greatest satisfaction, while sexual relations and
finances were reported as areas giving the least satisfaction.
were no differences in the total mean value of QOL between people who
had received one to three psychosocial interventions and those who had
received none, and between those who had received more than three
interventions compared to those without such experiences.
an alternative to examining whether psychosocial interventions had been
carried out in accordance with psychosocial models that were based on
strong evidence, or linked to fidelity scales as recommended when
evaluating psychosocial interventions (Dixon et al., 2011), our study
investigated the extent to which people with SMI living in the
community had been informed that psychosocial interventions were
available and had been provided with them.
We found that a
considerable number of our interviewees were both informed of and had
experienced different kinds of psychosocial interventions. This may be
because a majority of them were currently undergoing treatment from
psychiatric services, which was well aware of the value of psychosocial
interventions for people with SMI living in the community. Psychiatric
services might also have known of the relationship between psychosocial
interventions for people with schizophrenia and the reduction of
hospitalization costs, as earlier studies have shown (Panthunane,
2011). Almost all participants in our study managed to live in the
community without requiring hospitalization, which may be attributable
to the support they received from psychosocial interventions.
study found, in accordance with earlier research, that there is a
limited provision of family interventions for people with SMI.
According to a report from the US, less than 8% of all patients with
schizophrenia attended formal support programs with their families
(Resnick, Rosenheck, Dixon, & Lehman, 2005). In Germany, Austria,
and Switzerland only 2% of family members of patients with
schizophrenia had taken part in psychoeducational interventions
(Rummel-Kluge, Pitschel-Walz, Bäuml, & Kissling, 2006).
participants who received more than three different psychosocial
interventions were generally in independent living in apartments of
their own we do not know if this is an effect of psychosocial
interventions they received, or whether service providers are more
likely to support those living independently with such interventions.
Additionally, we do not know if the relationship found between being
younger, having a higher assessed QOL and receiving cognitive therapy
might manifest a service provider’s more willing engagement with
younger people or if younger people are more amenable to being
supported by psychotherapies.
We found no difference in
experiences of psychosocial interventions between people with a
self-stated diagnosis of schizophrenia or any other diagnoses, or no
known diagnosis. This might validate the use of our broader inclusion
criteria, that is, a population with SMI instead of a more restricted
schizophrenia spectrum disorder. Other researchers have similarly
employed this wider criteria (Ruggeri et al., 2000). However, our
findings may also be the result of services putting into practice the
PORT recommendations that psychosocial interventions be implemented not
only for people with a pure diagnosis of schizophrenia but for a more
general SMI population.
Researchers in areas of psychosocial
interventions mostly focus on the long-term outcome of a disorder for
chronic cases, such as individuals in their first episode of
schizophrenia (Addington, 2010) evidence-based psychosocial
intervention models are favored. In a cross-sectional study like ours,
the impact over time of treatment for a serious mental disorder cannot
be inferred from the findings: they merely provide a snapshot of the
social and functional status of outpatients, irrespective of their
current treatment plan. Furthermore, investigating aspects of the lives
of people with SMI living in the community that have not been
previously studied requires new approaches in order for assessments
procedures to be established. Since we found no instrument measuring
the users’ own point of view with regard to participation in a
psychosocial intervention, our initial task was to develop an
instrument whose psychometric properties will still need to be tested.
method of investigation and analysis does not allow us to distinguish
cause from effect, although our findings suggest that psychiatric
services do not only select well-functioning individuals with a
relatively high QOL for psychosocial interventions (NIMH Strategy Plan,
2008). However, since we determined a relationship between receiving
psychosocial interventions and being in independent living, other
factors may also be involved.
Our method has certain
shortcomings. A number of individuals we found eligible for the survey
could not be contacted or did not want to participate in the
investigation. We presume that people who are dissatisfied with the
care they receive are more likely to avoid taking part in a study
related to satisfaction with care. Furthermore, it has been shown that
asking someone with SMI living in a community to participate in a study
lowered the rate of participation without individuals giving a specific
reason for their decision (Beebe, 2010). Another shortcoming might be
that interviewing a participant in the presence of their contact person
may make the subject feel obliged to please the contact person by
giving more positive answers, since the contact represents the services
under investigation. Accordingly, participants in our study may have
overrated their satisfaction with the care they received. Finally,
although psychosocial interventions are evidence-based, they can be
delivered in many different formats according to the environment in
which they are applied.
A strength of this study is that the
data was gathered through patient interviews by means of extensive
questionnaires that collected specific information. This methodology is
useful when investigating a limited numbers of participants who are not
constrained by time.
Our study confirmed that in a population
including people with an SMI living in the community, many of the
latter were either informed of or received various psychosocial
interventions in addition to their regular symptom reduction treatment,
in accordance with international recommendations (Mental Health
Commission 1998), independently of their experienced QOL. Moreover, it
shows the limited amount of psychosocial family interventions in
relation to other psychosocial interventions the psychiatric services
place at people with SMI’s disposal. A finding which may be of
importance for these services if aiming to support the relationship
between people with SMI and their families.
In order to
generalise the findings of this study, a broader population of people
with SMI as well as populations of different countries and settings,
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