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Intervention Summary

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Psychiatric Rehabilitation Process Model

The Psychiatric Rehabilitation Process Model is a process guiding the interaction between a practitioner and an individual with severe mental illness. Manual driven, the model is a client-centered, strengths-based intervention designed to build clients' positive social relationships, encourage self-determination of goals, connect clients to needed human service supports, and provide direct skills training to maximize independence. One-on-one sessions are used to help clients access assistance in obtaining health, mental health, dental, and social services and develop and implement individual rehabilitation plans. The model, previously called the Choose-Get-Keep Model as well as Choices, can be implemented in a variety of mental health settings (e.g., hospitals, psychosocial rehabilitation centers, clubhouses and drop-in centers, residential programs, vocational programs, intensive day programs) by practitioners in most mental health disciplines. Practitioners must undergo a training program to implement the intervention.

In the study reviewed for this summary, the model was integrated into an intensive, one-on-one case management, psychiatric rehabilitation, and supported respite housing program for homeless clients with severe mental illness. By increasing the clients' ability to meet basic survival needs (such as getting enough food, finding a sheltered place to sleep, and keeping clean), maintain stable residential housing, and successfully access needed human services in the community, the program aimed to improve the clients' quality of life and psychological symptoms. In the study, the intervention provided clients a low-demand drop-in center during the day, with food, showers, and other desirable resources, and nightly respite housing, available in 10-bed blocks through arrangements with church-based shelters or community YMCAs. Clients could participate in optional structured group activities at the center as well as one-on-one case management sessions to access assistance in obtaining services and in developing and implementing individual rehabilitation plans. Clients received support for 6 months to 2 years, depending on their needs. The services provided in the study reviewed for this summary (e.g., drop-in center, housing) are not components of the currently available intervention.

Descriptive Information

Areas of Interest Mental health treatment
Co-occurring disorders
Outcomes Review Date: September 2011
1: Ability to meet basic survival needs
2: Housing status
3: Use of human services
4: Quality of life
5: Psychological symptoms of anxiety, depression, and thought disturbance
Outcome Categories Homelessness
Mental health
Quality of life
Treatment/recovery
Ages 18-25 (Young adult)
26-55 (Adult)
55+ (Older adult)
Genders Male
Female
Races/Ethnicities Black or African American
Race/ethnicity unspecified
Settings Other community settings
Geographic Locations Urban
Implementation History The Psychiatric Rehabilitation Process Model, previously called the Choose-Get-Keep Model and Choices, was first implemented in 1982. Since then, it has been implemented in over 100 organizations and approximately 400 separate programs in at least 41 States or territories and 13 countries outside the United States. More than 10,000 individuals have participated in the intervention.
NIH Funding/CER Studies Partially/fully funded by National Institutes of Health: Yes
Evaluated in comparative effectiveness research studies: Yes
Adaptations Intervention materials have been translated into Dutch, French, and Italian.
Adverse Effects No adverse effects, concerns, or unintended consequences were identified by the developer.
IOM Prevention Categories IOM prevention categories are not applicable.

Quality of Research
Review Date: September 2011

Documents Reviewed

The documents below were reviewed for Quality of Research. The research point of contact can provide information regarding the studies reviewed and the availability of additional materials, including those from more recent studies that may have been conducted.

Study 1

Shern, D. L., Tsemberis, S., Anthony, W., Lovell, A. M., Richmond, L., Felton, C. J., et al. (2000). Serving street-dwelling individuals with psychiatric disabilities: Outcomes of a psychiatric rehabilitation clinical trial. American Journal of Public Health, 90(12), 1873-1878.  Pub Med icon

Supplementary Materials

Barrow, S. M. (2009). Personal History Form. Columbia Center for Homelessness Prevention Studies: Compendium of homelessness and housing measures.

Lehman, A. F. (1988). A quality of life interview for the chronically mentally ill. Evaluation and Program Planning, 11, 51-62.

Lovell, A. M., & Cohn, S. (1998). The elaboration of "choice" in a program for homeless persons labeled psychiatrically disabled. Human Organization, 57(1), 8-20.

Rogers, E. S., Cohen, B. F., Danley, K. S., Hutchinson, D., & Anthony, W. A. (1986). Training mental health workers in psychiatric rehabilitation. Schizophrenia Bulletin, 12(4), 709-719.  Pub Med icon

Shern, D. L., Felton, C. J., Hough, R. L., Lehman, A. F., Goldfinger, S., Valencia, E., et al. (1997). Housing outcomes for homeless adults with mental illness: Results from the second-round McKinney program. Psychiatric Services, 48(2), 239-241.  Pub Med icon

Shern, D. L., Trochim, W. M. K., & LaComb, C. A. (1995). The use of concept mapping for assessing fidelity of model transfer: An example from psychiatric rehabilitation. Evaluation and Program Planning, 18(2), 143-153.

Shern, D. L., Wilson, N. Z., Coen, A. S., Patrick, D. C., Foster, M., Bartsch, D. A., et al. (1994). Client outcomes II: Longitudinal client data from the Colorado Treatment Outcome Study. Milbank Quarterly, 72(1), 123-148.  Pub Med icon

Street Study: 2-Week Service Utilization Interview. (1991).

Street Study: 6-Month Follow-Up Interview. (1992).

Outcomes

Outcome 1: Ability to meet basic survival needs
Description of Measures The ability to meet basic survival needs such as getting food, having a place to sleep, getting clothing, keeping clean, finding a bathroom, and keeping possessions was measured using the Brief, 2-Week Service Utilization and Housing Status Interview. Adapted from the Personal History Form used by the Columbia University Center for Homelessness Prevention Studies, the brief questionnaire uses a structured calendar format with probes to help the respondent recall where he or she slept on each of the past 14 nights and indicate which formal and informal human service resources he or she used to meet basic survival, health, mental health, chemical abuse, and social service needs during this time. Respondents provide the number of times each type of service was used and the degree of difficulty experienced in obtaining each type of service on a 4-point scale from 1 (usually) to 4 (never).

The questionnaire was administered at about 7-week intervals across a 2-year study period. For each participant, a change score was calculated for each basic need by subtracting the baseline score from the average score across the available follow-ups.
Key Findings In a 2-year randomized clinical trial, street-dwelling individuals with severe mental illness were assigned to groups to receive either the intervention or standard treatment, which involved a range of programs (e.g., outreach services, drop-in centers, case management programs, mental health and general health services, soup kitchens, municipal and private shelters, specialized municipal shelters for persons with psychiatric disabilities). For the intervention group, special relationships with housing providers were established and an intervention-specific housing program was eventually developed to help ensure access to long-term housing for difficult-to-place clients. Compared with standard treatment participants, intervention participants had a greater improvement in difficulty getting food (p = .003), having a place to sleep (p = .003), and keeping clean (p = .003), according to the average score across follow-ups relative to baseline for each measure.
Studies Measuring Outcome Study 1
Study Designs Experimental
Quality of Research Rating 3.1 (0.0-4.0 scale)
Outcome 2: Housing status
Description of Measures Housing status was assessed as the percentage of the past 14 nights spent on the streets, in shelters, in community living situations (i.e., hotel rooms, community residences, apartments), and in institutions (i.e., psychiatric, medical, and forensic inpatient facilities) using the Brief, 2-Week Service Utilization and Housing Status Interview. Adapted from the Personal History Form used by the Columbia University Center for Homelessness Prevention Studies, the brief questionnaire uses a structured calendar format with probes to help the respondent recall where he or she slept on each of the past 14 nights and indicate which formal and informal human service resources he or she used to meet basic survival, health, mental health, chemical abuse, and social service needs during this time. Additionally, respondents are asked to rate the degree of difficulty experienced in finding a place to sleep on a 4-point scale from 1 (usually) to 4 (never).

The questionnaire was administered at about 7-week intervals across a 2-year study period. For each participant, a change score was calculated for each type of housing setting by subtracting the baseline percentage of the prior 14 nights spent in that setting from the percentage of the past 14 nights spent in that setting averaged across all available follow-ups.
Key Findings In a 2-year randomized clinical trial, street-dwelling individuals with severe mental illness were assigned to groups to receive either the intervention or standard treatment, which involved a range of programs (e.g., outreach services, drop-in centers, case management programs, mental health and general health services, soup kitchens, municipal and private shelters, specialized municipal shelters for persons with psychiatric disabilities). For the intervention group, special relationships with housing providers were established and an intervention-specific housing program was eventually developed to help ensure access to long-term housing for difficult-to-place clients. Findings from this study included the following:

  • Although participants in both conditions had a decrease in the percentage of nights spent on the streets averaged across all available follow-ups relative to baseline, this decrease was larger for intervention participants than standard treatment participants (-54.9% vs. -28.2%; p < .001).
  • Compared with standard treatment participants, intervention participants had a larger increase in the percentage of nights spent in shelters (using the intervention-provided housing almost exclusively) averaged across all available follow-ups relative to baseline (+2.8% vs. +23.1%; p = .001).
  • Compared with standard treatment participants, intervention participants had a larger increase in the percentage of nights spent in community living averaged across all available follow-ups relative to baseline (+9.9% vs. +21.0%; p = .025).
Studies Measuring Outcome Study 1
Study Designs Experimental
Quality of Research Rating 3.0 (0.0-4.0 scale)
Outcome 3: Use of human services
Description of Measures Use of human services--defined as cash entitlement, health insurance, emergency department, psychiatric medications, outpatient or inpatient psychiatric care or alcohol/drug treatment, psychiatric day program, outreach, self-help support groups, dental care, police contact, jail time, court involvement, or any other help--was measured using the Brief, 2-Week Service Utilization and Housing Status Interview. Adapted from the Personal History Form used by the Columbia University Center for Homelessness Prevention Studies, the brief questionnaire uses a structured calendar format with probes to help the respondent recall where he or she slept on each of the past 14 nights and indicate which formal and informal human service resources he or she used to meet basic survival, health, mental health, chemical abuse, and social service needs during this time. Respondents provide the number of times each type of service was used and the degree of difficulty experienced in obtaining each type of service on a 4-point scale from 1 (usually) to 4 (never). The adapted Personal History Form was also used as part of a longer structured interview.

The questionnaire was administered at about 7-week intervals across a 2-year study period. The longer structured interview was conducted at 6-month intervals across the 2-year period. For each human service, the percentage of participants who reported using the service at least once in a 6-month follow-up period was averaged across all available follow-ups.
Key Findings In a 2-year randomized clinical trial, street-dwelling individuals with severe mental illness were assigned to groups to receive either the intervention or standard treatment, which involved a range of programs (e.g., outreach services, drop-in centers, case management programs, mental health and general health services, soup kitchens, municipal and private shelters, specialized municipal shelters for persons with psychiatric disabilities). For the intervention group, special relationships with housing providers were established and an intervention-specific housing program was eventually developed to help ensure access to long-term housing for difficult-to-place clients. A higher average percentage of intervention than standard treatment participants reported attending a psychiatric day program (e.g., the intervention drop-in center) at least once at the 6-month follow-ups across the 2-year study (52.7% vs. 27.3%; p = .001).
Studies Measuring Outcome Study 1
Study Designs Experimental
Quality of Research Rating 3.0 (0.0-4.0 scale)
Outcome 4: Quality of life
Description of Measures Quality of life was measured using the Quality of Life Interview for individuals with chronic mental illness, a 45-minute structured interview of 153 items that asks respondents to rate their general (global) satisfaction with life and their satisfaction with life across the following 8 domains: living situation, leisure (daily activities and functioning), family relations, social relations, finances, work/school, legal/safety issues, and health. Each item is rated on a 7-point scale from 1 (terrible) to 7 (delighted). The living situation domain was not used in the study.

The Quality of Life Interview was conducted as part of a structured interview at 6-month intervals across a 2-year study period. For each participant, a change score was calculated for each life domain and for global satisfaction by subtracting the baseline score from the average score across the available follow-ups.
Key Findings In a 2-year randomized clinical trial, street-dwelling individuals with severe mental illness were assigned to groups to receive either the intervention or standard treatment, which involved a range of programs (e.g., outreach services, drop-in centers, case management programs, mental health and general health services, soup kitchens, municipal and private shelters, specialized municipal shelters for persons with psychiatric disabilities). For the intervention group, special relationships with housing providers were established and an intervention-specific housing program was eventually developed to help ensure access to long-term housing for difficult-to-place clients. Compared with standard treatment participants, intervention participants had greater improvement in global satisfaction with life (p = .001) and satisfaction with the life domains of leisure (p = .027), finances (p = .001), legal/safety issues (p = .005), health (p = .006), and family relations (p = .005), according to the average score across follow-ups relative to baseline for each measure.
Studies Measuring Outcome Study 1
Study Designs Experimental
Quality of Research Rating 3.4 (0.0-4.0 scale)
Outcome 5: Psychological symptoms of anxiety, depression, and thought disturbance
Description of Measures Psychological symptoms of anxiety, depression, and thought disturbance were measured using the Colorado Symptom Index, a 15-item self-report scale that asks respondents to rate the frequency of specific psychological symptoms in the past month on a 5-point scale from "at least every day" to "not at all." Items address symptoms of anxiety (e.g., "In the past month, how often have you felt nervous, tense, worried, frustrated, or afraid?"), depression (e.g., "In the past month, how often have you felt depressed?"), and thought disturbance (e.g., "In the past month, how often did you hear voices, or hear or see things that other people didn't think were there?"). The total Colorado Symptom Index score is the sum of ratings across all 15 items, with a higher total score representing more frequent symptoms.

The Colorado Symptom Index was administered as part of a structured interview at 6-month intervals across a 2-year study period. For each participant, a change score was calculated for the total Colorado Symptom Index score by subtracting the baseline score from the average score across the available follow-ups.
Key Findings In a 2-year randomized clinical trial, street-dwelling individuals with severe mental illness were assigned to groups to receive either the intervention or standard treatment, which involved a range of programs (e.g., outreach services, drop-in centers, case management programs, mental health and general health services, soup kitchens, municipal and private shelters, specialized municipal shelters for persons with psychiatric disabilities). For the intervention group, special relationships with housing providers were established and an intervention-specific housing program was eventually developed to help ensure access to long-term housing for difficult-to-place clients. Compared with standard treatment participants, intervention participants had reductions in anxiety, depression, and thought disturbance symptoms (total Colorado Symptom Index score, p = .007), according to the average score across follow-ups relative to baseline.
Studies Measuring Outcome Study 1
Study Designs Experimental
Quality of Research Rating 3.4 (0.0-4.0 scale)

Study Populations

The following populations were identified in the studies reviewed for Quality of Research.

Study Age Gender Race/Ethnicity
Study 1 18-25 (Young adult)
26-55 (Adult)
55+ (Older adult)
76% Male
24% Female
61% Black or African American
39% Race/ethnicity unspecified

Quality of Research Ratings by Criteria (0.0-4.0 scale)

External reviewers independently evaluate the Quality of Research for an intervention's reported results using six criteria:

  1. Reliability of measures
  2. Validity of measures
  3. Intervention fidelity
  4. Missing data and attrition
  5. Potential confounding variables
  6. Appropriateness of analysis

For more information about these criteria and the meaning of the ratings, see Quality of Research.

Outcome Reliability
of Measures
Validity
of Measures
Fidelity Missing
Data/Attrition
Confounding
Variables
Data
Analysis
Overall
Rating
1: Ability to meet basic survival needs 2.8 2.5 3.3 3.8 3.0 3.5 3.1
2: Housing status 2.8 2.5 3.3 3.5 2.5 3.5 3.0
3: Use of human services 2.8 2.5 3.3 3.5 2.5 3.5 3.0
4: Quality of life 3.8 3.8 3.3 3.5 2.5 3.5 3.4
5: Psychological symptoms of anxiety, depression, and thought disturbance 3.8 3.8 3.3 3.5 2.5 3.5 3.4

Study Strengths

The two measurement instruments used, the Brief, 2-Week Service Utilization and Housing Status Interview and the longer structured interview, were created from well-known scales in the field with strong reliability and validity documented by independent investigators. Efforts to ensure intervention fidelity included use of a manual-driven training program based on concept maps of the key elements necessary for implementing the intervention with high fidelity, as well as ongoing supervision of interventionists by the research investigators during the study. Participant attrition across the 24 months of follow-up was handled using an intent-to-treat approach, and missing follow-up data were handled by averaging each participant's follow-up measurements and calculating a change from baseline. Random assignment controlled for many potential confounds. The statistical analyses were appropriate.

Study Weaknesses

No sample reliability or validity data were provided for the Brief, 2-Week Service Utilization and Housing Status Interview or the longer structured interview. No instrument was used to measure fidelity. There was differential participant attrition across the two study conditions, with fewer intervention participants lost to follow-up. Missing data across study participants were highly variable, with a wide range of available assessments across participants (range = 1-55 assessments, median = 12 assessments).

Readiness for Dissemination
Review Date: September 2011

Materials Reviewed

The materials below were reviewed for Readiness for Dissemination. The implementation point of contact can provide information regarding implementation of the intervention and the availability of additional, updated, or new materials.

Anthony, W. A., & Farkas, M. D. (2009). Primer on the Psychiatric Rehabilitation Process. Boston: Boston University, Center for Psychiatric Rehabilitation.

Boston University, Center for Psychiatric Rehabilitation. (2008). Psychiatric rehabilitation supervisor coaching forms. Boston, MA: Author.

Boston University, Center for Psychiatric Rehabilitation. (2008). Psychiatric rehabilitation supervisor coaching guide. Boston, MA: Author.

Cohen, M. R., Danley, K. S., & Nemec, P. B. (1985). Psychiatric rehabilitation training technology: Direct skills training. Boston, MA: Boston University, Center for Psychiatric Rehabilitation.

Cohen, M. R., Farkas, M., & Cohen, B. F. (1986). Psychiatric rehabilitation training technology: Functional assessment. Boston, MA: Boston University, Center for Psychiatric Rehabilitation.

Cohen, M. R., Farkas, M., Cohen, B. F., & Unger, K. V. (1991). Psychiatric rehabilitation training technology: Setting an overall rehabilitation goal. Boston, MA: Boston University, Center for Psychiatric Rehabilitation.

Cohen, M. R., Forbess, R., & Farkas, M. (2000). Psychiatric rehabilitation training technology: Developing rehabilitation readiness. Boston, MA: Boston University, Center for Psychiatric Rehabilitation.

Cohen, M. R., Nemec, P. B., Farkas, M., & Forbess, R. (1988). Psychiatric rehabilitation training technology: Case management. Boston, MA: Boston University, Center for Psychiatric Rehabilitation.

Farkas, M., Cohen, M. R., McNamara, S., Nemec, P. B., & Cohen, B. (2000). Psychiatric rehabilitation training technology: Assessing rehabilitation readiness. Boston, MA: Boston University, Center for Psychiatric Rehabilitation.

Farkas, M., Sullivan-Soydan, A., & Gagne, C. (2000). Introduction to rehabilitation readiness. Boston, MA: Boston University, Center for Psychiatric Rehabilitation.

Luijten, E., van Busschbach, J. T., & Swildens, W. (n.d.). Fidelity psychiatric rehabilitation approach (PR): Fidelity instrument for psychiatric rehabilitation in the Netherlands.

Program Web site, http://www.bu.edu/cpr/

Rehabilitation Readiness brochure

Readiness for Dissemination Ratings by Criteria (0.0-4.0 scale)

External reviewers independently evaluate the intervention's Readiness for Dissemination using three criteria:

  1. Availability of implementation materials
  2. Availability of training and support resources
  3. Availability of quality assurance procedures

For more information about these criteria and the meaning of the ratings, see Readiness for Dissemination.

Implementation
Materials
Training and Support
Resources
Quality Assurance
Procedures
Overall
Rating
3.3 3.3 3.5 3.3

Dissemination Strengths

Each implementation kit is well organized and comprehensive. The inclusion of prompts within the materials (e.g., "ask," "tell," "show," "make the point") helps implementers follow the intended process. The primer on the intervention provides an introduction to the model and emphasizes the importance of tracking client progress throughout the course of treatment. Trainer orientation guides for each module provide detailed instructions and tips to help trainers organize, deliver, and evaluate training sessions. Training is interactive and experiential, emphasizing participant discussion and practice. The client progress tracking forms and practitioner checklists are well designed and easy to use. The progress tracking forms can be used in clinical supervision to assess the quality of implementation and assist the practitioner in improving skills. Pre- and posttests for each training module and trainer review of videotaped clinical sessions are used to assess practitioner mastery of program steps and skills.

Dissemination Weaknesses

Clear instruction is lacking on the intended sequence of materials and conditions under which the materials are to be used. Guidance is not provided on some critical components of implementation, such as staffing, administrative, and operational requirements. Information about training and program support on the Web site is limited. Implementation sites not accustomed to conducting research may have difficulty using the fidelity assessment tools, and assistance with this process is limited. While tools are available to help practitioners track the progress of clients over the course of treatment, there are no guidelines for analyzing or interpreting the data collected.

Costs

The cost information below was provided by the developer. Although this cost information may have been updated by the developer since the time of review, it may not reflect the current costs or availability of items (including newly developed or discontinued items). The implementation point of contact can provide current information and discuss implementation requirements.

Item Description Cost Required by Developer
Training kit for each component (Rehabilitation Readiness, Setting an Overall Rehabilitation Goal, Functional Assessment, Direct Skills Training, and Case Management) $198-250 per kit Yes, for each component to be implemented
Activity Compendium $19.95 No
Supervisor Coaching Guide Free Yes
Service Planning Guide Free No
Primer on the Psychiatric Rehabilitation Process Free No
On- and off-site training for practitioners to achieve expertise in the model $850-875 per day for 10-12 participants, plus travel expenses, with cost and duration depending on site needs Yes
Posttraining supervised follow-up (at the time of on-site training to achieve expertise in the model) $875 per person, per component Yes
On- or off-site training for practitioners to gain experience in the model $875 per day for up to 15 participants, plus travel expenses, with duration depending on site needs No
3-day, on- or off-site training for practitioners to gain exposure to the model $2,625 for 20-30 participants, plus travel expenses No
On- or off-site training for supervisors $875 per day for 10-12 participants, plus travel expenses, with duration depending on site needs Yes, if change in agency practice is a goal
Technical assistance in various areas (e.g., policies, procedures, activities, record keeping, job descriptions, performance appraisal) $825-$1,000 per day, plus travel expenses, with cost and duration depending on site needs No
Psychiatric Rehabilitation Process Outcome Guide Free No
Replications

Selected citations are presented below. An asterisk indicates that the document was reviewed for Quality of Research.

Dunn, E. C., Rogers, E. S., Hutchinson, D. S., Lyass, A., MacDonald Wilson, K. L., Wallace, L. R., et al. (2008). Results of an innovative university-based recovery education program for adults with psychiatric disabilities. Administration and Policy in Mental Health, 35(5), 357-369.  Pub Med icon

Ellison, M. L., Anthony, W. A., Sheets, J., Dodds, W., Barker, W. J., Massaro, J., et al. (2002). The integration of psychiatric rehabilitation services in behavioral health care structures: A State example. Journal of Behavioral Health Services and Research, 29(4), 381-393.  Pub Med icon

Hutchinson, D., Anthony, W. A., Massaro, J., & Rogers, E. S. (2007). Evaluation of a combined supported education and employment computer training program for persons with psychiatric disabilities. Psychiatric Rehabilitation Journal, 30(3), 189-197.  Pub Med icon

Kramer, P., Anthony, W. A., Rogers, S. R., & Kennard, W. A. (2003). Another way of avoiding the "single model trap." Psychiatric Rehabilitation Journal, 26(4), 413-415.  Pub Med icon

* Shern, D. L., Tsemberis, S., Anthony, W., Lovell, A. M., Richmond, L., Felton, C. J., et al. (2000). Serving street-dwelling individuals with psychiatric disabilities: Outcomes of a psychiatric rehabilitation clinical trial. American Journal of Public Health, 90(12), 1873-1878.  Pub Med icon

Swildens, W., van Busschbach, J. T., Michon, H., Kroon, H., Koeter, M. W., Wiersma, D., et al. (2011). Effectively working on rehabilitation goals: 24-month outcome of a randomized controlled trial of the Boston psychiatric rehabilitation approach. Canadian Journal of Psychiatry, 56(12), 751-760.   Pub Med icon

Contact Information

To learn more about implementation, contact:
Marianne Farkas, Sc.D.
(617) 353-3549
mfarkas@bu.edu

To learn more about research, contact:
E. Sally Rogers, Sc.D.
(617) 353-3549
erogers@bu.edu

Consider these Questions to Ask (PDF, 54KB) as you explore the possible use of this intervention.