Evidence-Based Processes in an Era of Recovery

Abstract

Evidence-based practice initiatives pertaining to helping people recover from severe mental illnesses have designated certain practices as evidence-based (e.g., supported employment, intensive case management) due to their ability to generate positive outcomes in randomized trials. These practices are often described mostly in terms of their program structures, such as staffing or caseload size. However, evidence-based practice initiatives would benefit from deliberately integrating the factors in the helping process that can occur within each program, and which other mental health research has shown to foster change and growth (i.e., relationship variables, skill teaching strategies, hope-engendering techniques). This article overviews the research underlying those evidence-based helping processes that have often been overlooked in the study of evidence-based practices with respect to interventions for people with severe mental illnesses. Implications for policy and rehabilitation counseling are addressed to expand the evidence base to include evidence-based processes for rehabilitation counseling and research.

Keywords

psychiatric disability(ies)mental illness rehabilitation counseling rehabilitation research design

Introduction

Prior to the current focus on evidence-based practices (Wilson, Armoutliev, Yakunina, & Werth, 2009) was the development of the recovery movement in the last several decades of the 20th century. Recovery involved the notion that people with severe mental illnesses could recover and function within the natural community, rather than just be maintained in the mental health service community. Recovery from severe mental illnesses was seen as a legitimate vision to guide mental health practice and policy. The vision of recovery from severe mental illnesses was brought to the field by the writings of current and former service recipients (Chamberlin, 1978; Deegan, 1988), and solidified by the long-term research conducted and synthesized by Harding (2003). While many definitions of recovery have been suggested, the various definitions are somewhat similar in that the vision of recovery implies that people with severe mental illnesses can develop new meaning and purpose in their lives as they learn to deal with the challenges of severe mental illnesses (Anthony, 1993). Many graduate training programs in rehabilitation counseling and clinical work have been funded to develop rehabilitation counseling curriculum that explains recovery-related principles and practices (Clay, 2012).

A number of key principles are inherent in the recovery vision for rehabilitation counseling. One of the most fundamental recovery principles is the principle of “people-first,” (i.e., people with mental illnesses are individuals before they are cases, diagnoses, or patients; Titchkosky, 2001). They are not, as the mental health field has mistakenly emphasized, primarily defined and governed by their symptoms and diagnoses. Rather, the people-first principle assumes that people with severe mental illnesses primarily live their own lives like their non-diagnosed counterparts. They too are helped in their development by the same helping processes that assist all people to live a meaningful life (Anthony, 2004).

Currently, the evidence-based practice initiative for people with severe mental illnesses has designated certain practices as evidence-based practices (e.g., supported employment, intensive case management) due to their ability to generate positive outcomes in randomized trials (Bond, Drake, & Becker, 2012; Sells, Davidson, Jewell, Falzer, & Rowe, 2006). These evidence-based practices are described mostly by their program structures such as staffing, service location, or caseload size (Salyers & Tsemberis, 2007). At times, the evidence-based practice models underemphasize the key ingredients of the helping process that occur within each practice and which extant mental health research has shown to contribute to change and growth (relationship variables, hope engendering techniques, etc.).

This editorial provides a follow-up to a previous article that was published over a decade ago to call for the inclusion of human interaction processes in evidence-based practices (Anthony, 2003). Given that we have not seen significant change in this regard, this article updates this previous editorial and provides further overview of the research underlying those evidence-based helping processes that have often been overlooked in the study of evidence-based practices with respect to interventions for people with severe mental illnesses. Implications for policy and rehabilitation counseling are addressed to expand the evidence base to include evidence-based processes for rehabilitation counseling and research.

Expanding the Evidence Base

By definition, evidence-based practice integrates “individual clinical expertise with the best available external clinical evidence from systematic research . . . By best available external clinical evidence we mean clinically relevant research . . . ” (Sackett, Rosenberg, Gray, Haynes, & Richardson, 1996, p. 71). The American Psychological Association (APA) Presidential Task Force used a three-legged definition of evidence-based practice: “the integration of the best available research with clinical expertise in the context of patient characteristics, culture and preferences” (APA Presidential Task Force on Evidence-Based Practice, 2006, p. 273). With respect to the field of severe mental illnesses, “clinically relevant research” or “best available research” has typically been confined to studies in the mental health services research arena. Yet the behavioral science research literature (i.e., research conducted in laboratory rather than in clinical practice) on how people change and grow, not just people with severe mental illnesses but all types of people, is what becomes relevant under a people-first principle. In this regard, the mental health services research literature (i.e., clinical research that is practice-based) has identified certain human interactive processes that help people change and grow. These evidence-based helping processes include the following:

people experiencing a positive relationship with the people providing help,

people setting their own goals,

people encouraged to have positive expectancies and hope for change,

people being taught new skills,

people developing self awareness (insight) about aspects of their own behavior, and

people feeling supported.

Evidence-based practices for helping people with severe mental illnesses can be improved by incorporating into program structures what we term here as “evidence-based processes.” Without compromising fidelity to the structure of the particular program model, the aforementioned evidence-based processes can be integrated within the program model. These evidence-based processes, akin to common factors, cut across program labels and can add outcome variance to the evidence-based practices.

To advance this notion that evidence-based processes are essential to promoting mental health outcomes, the following section samples the research in psychology that is “clinically relevant” to helping people with severe mental illnesses recover, as well as mental health services research relevant to these helping processes in rehabilitation counseling. Several examples of implications for rehabilitation counseling practice and policy are noted.

Relationship Between Provider and Recipient

In the field of psychology, research on the importance of the relationship between the counselor and the person being helped may contain the strongest positive outcomes (Safran & Muran, 2000). The relationship between the person served and the counselor has been shown to be important to outcomes in psychotherapy, education, and medicine (Birch & Ladd, 1998; Safran & Muran, 2000; Stewart, McWhinney, & Buck, 1979). This relationship has been referred to as the therapeutic alliance, therapeutic relationship, or working alliance (McCabe & Priebe, 2004). The therapeutic alliance is defined as the relationship between the therapist and client formed in collaborating on overcoming the client’s presenting problem (Bordin, 1979).

Of all the areas of research in psychology which translate to interventions for people with severe mental illnesses, the research on relationship variables has been incorporated most readily into the mental health services research arena (Chinman, Rosenheck, & Lam, 2000; Green et al., 2008; Ware, Tugenberg, & Dickey, 2004). Collaboration in the therapeutic relationship can be powerful in producing outcomes greater than the individual efforts of either the practitioner or the patient alone (McCabe & Priebe, 2004; Suchman, 2006). Some of the clinical outcomes associated with the therapeutic alliance have included treatment satisfaction (McCabe & Priebe, 2004) and active participation in the rehabilitation process (Lustig, Strauser, Rice, & Rucker, 2002). A satisfying, long-term relationship with the same provider has been associated with increased quality of life, satisfaction with medications, and reduced symptoms for people with mental illnesses (Green et al., 2008). Moreover, other specific outcomes have been described, such as in the alliance between homeless clients and case managers, with stronger alliances being associated with fewer days of homelessness and general life satisfaction (Chinman et al., 2000).

These findings on the therapeutic alliance suggest that this research has been integrated into rehabilitation counseling. However, this research has not easily found its way into mental health policy. This research may be ahead of the policy given issues related to the time needed to develop a helping relationship, the lack of funding for this task, and the neglect of training for mental health practitioners in this area. There is sufficient evidence to include these evidence-based processes in rehabilitation practice, and policy makers should therefore change current policies to ensure their inclusion. Policy makers committed to furthering these evidence-based processes can ensure that rehabilitation programs—be they medication management, intensive case management, or family psychoeducation—provide the time, financial resources, and staff expertise for positive relationships to develop. Particularly, people who set policy in the vocational rehabilitation arena (e.g., State Division of Vocational Rehabilitation Directors; Commissioners of State Departments of Mental Health, the Social Security Administration, the Veterans Administration, CEOs of Managed Care Firms) need to be targeted. These policy makers must consider the effort that goes into developing a working alliance and other evidence-based processes as critical to the outcome/process of vocational rehabilitation and set their policies accordingly. Vocational rehabilitation policy makers must allow for the time needed to achieve this working alliance.

Goal Setting

Beginning with laboratory research, the study of the effects of goal setting on people’s behavior has a long history in behavioral science (Locke, Shaw, Saari & Latham, 1981). These early laboratory studies have demonstrated the positive effects on a person’s performance when goals are set, and when the person has a say in what particular goals are put forward. For example, goal setting research has indicated that perceived self-efficacy and setting personal goals are the most predictive of success (Bandura & Locke, 2003). Goal setting can have a positive impact on a person’s future aspirations and ability to think strategically (Wood & Bandura, 1989). Goals can enhance creativity (Locke, Frederick, Lee, & Bobko, 1984) as well as performance (Bandura & Cervone, 1983, 1986).

Past and present performance on goals tends to be mediated by beliefs about one’s ability to be efficacious (Bandura, 1997; Bandura & Locke, 2003; Powers, 1991). Framing feedback in terms of goal achievement and steps toward progress has been shown to be helpful in enhancing self-efficacy, personal satisfaction, and productivity (Jourden, 1991). In general, the goal setting research suggests that with meaningful goals and sufficient resources, people can be supported to achieve their goals.

Interestingly, in the mental health services research arena, early rehabilitation counseling research suggested that the rehabilitation goals of people using services frequently differed from goals that service providers had for them (Dellario, Goldfield, Farkas, & Cohen, 1984; Makas, 1980). This literature indicated that providers often are inaccurate in their assumptions about service user goals. This literature reinforced the necessity of engaging people in rehabilitation counseling interventions that incorporate a person-centered goal setting process (Shern et al., 2000). An example is the Choose-Get-Keep (CGK) psychiatric rehabilitation approach, which included training providers in how people with severe mental illnesses can be helped to set and achieve their own goals (Anthony, Cohen, Farkas, & Gagne, 2002; Rogers, Anthony, & Farkas, 2006).

Results from several studies on the clinical application of goal setting have indicated a positive relationship between choice and rehabilitation outcomes (Becker, Drake, Farabaugh, & Bond, 1996; Mueser, Becker, & Wolfe, 2001). The emphasis on the positive power of goal setting has given rise to the current focus on person-centered planning practices in interventions for people with severe mental illnesses (Borg, Karlsson, Tondora, & Davidson, 2009).

The historical lack of a people-first recovery principle has resulted in the goal setting research in psychology at times being overlooked by the mental health field. In the past, people with severe mental illnesses have rarely had a role in identifying their goals, and providers were rarely trained in how to help people set goals. Policy makers should insure that clinical procedures allow for self-determination of goals, that self-determined goals are regularly documented in the client records, and that programs have the trained staff with the opportunities to do this. Research from psychology, augmented by more recent rehabilitation counseling research, would indicate this is an appropriate direction.

Positive Expectancy or Hope

The psychology literature on hope has pointed to the motivational effect on performance of positive expectancies (Schrank, Stanghellini, & Slade, 2008). Early research on hope has described this construct as a clear expectation that one’s goals can be met (Snyder, Irving, & Anderson, 1991). A lack of hope has been linked with multiple mental health problems, including depression, anxiety, and suicidal ideation (Farran, Herth, & Popovich, 1995). In fact, hopelessness has been identified as a central warning sign of suicidality (Beck, Brown, & Steer, 1989).

Many users of rehabilitation counseling have advocated for an understanding of the power of hope in inspiring recovery (Deegan, 1988; Weingarten, 1994). Hope has been identified as a critical component in psychiatric rehabilitation practice (Anthony & Liberman, 1986) and in effective counseling in general (Babits, 2001). Hope can inspire positive expectations and lead to additional involvement in positive activities, improving social and occupational functioning (Russinova, 1999).

A lack of hope can be problematic for people with severe mental illnesses who are striving to recover (Anthony, 1993). Many people in recovery cite the lack of hope communicated by providers as leading to their own despair (Deegan, 1988). In contrast, providers can promote a sense of hope with regard to beliefs about the potential for recovery through the utilization of techniques and strategies to promote hope (Russinova, 1999).

At a systems level, the field of severe mental illnesses can make better use of the empirical knowledge on people’s recovery potential to portray a more hopeful field. The diagnostic system up until the Diagnostic and Statistical Manual of Mental Disorders (3rd ed., rev.; DSM-III-R; APA, 1987) described schizophrenia as a disease “characterized by acute exacerbations with increasing deterioration between episodes.” The result for service recipients within the mental health system was often the removal of positive expectancy and resignation to a life of hopelessness (Deegan, 1988, 1990). However, consistent with an empirical analysis of long-term studies (Harding, 1994, 2003) and the vision of recovery, as well as the supportive data from studies in the behavioral sciences, policy makers should set a theme that positive behavioral change is not only possible but to be expected. Policy makers’ speeches and writings have to communicate this message of hope to the persons served, their families, their paid helpers, and society. A field that is committed to bringing about behavioral change cannot continue to communicate a message of hopelessness that is antagonistic to people’s efforts to change.

Skills Teaching

Studies about how people best learn skills are found in both behavioral sciences research and mental health services research. Decades ago, behavioral science developed and researched skills teaching programs in such areas as social skills, vocational skills, life skills, and coping skills. This research has demonstrated the value of skill development across the life span to enhance functioning and satisfaction in one’s work, community, and mental wellness (Kincheloe, 1999; Lazarus & Folkman, 1984; Schneider & Byrne, 1985). In contrast, at one time in the field of severe mental illnesses, it was felt that people with such diagnoses could not learn skills (Anthony, 1979), primarily because of symptom interference. Now the literature has come to acknowledge that people with severe mental illnesses can learn skills in spite of their symptoms (Bellack, 2004).

A number of technologies have been developed in the mental illness field to facilitate skills teaching. Social skills training is one of the primary skills training interventions for mental health treatment and rehabilitation programs (Bellack, 2004; Kopelowicz, Liberman, & Zarate, 2006; Liberman, 1998) and has been effective in improving community functioning and activities of daily living (Dixon et al., 2009). Other relevant interventions include Direct Skills Teaching (Cohen, Danley, & Nemec, 1985), developed to help practitioners collaboratively identify rehabilitation goals with the consumer and then practice related skills in natural environments (Farkas & Anthony, 2010). Cognitive remediation is another type of skills development that improves cognitive skills for people with schizophrenia, including reason, attention, and memory to enhance functioning such as in employment settings (McGurk, Twamley, Sitzer, McHugo, & Mueser, 2007). Last, Cognitive Skills Training provides skills development in processing of emotions, social perception, and attributions made by people with psychotic symptoms, and has demonstrated positive outcomes in social perception and management of emotions (Horan et al., 2009).

Despite the many skills teaching technologies, mental health policy makers have been slow to consider educational environments and educational interventions as critical, primarily due to the aforementioned myth that people with severe mental illness diagnoses could not learn skills (Anthony 1979; Anthony & Margules, 1974). Vestiges of this myth have hindered the notion of using educational interventions and the educational environment as a primary treatment and rehabilitation site. Methods to fund and increase supported education opportunities (Mowbray & Megivern, 1992) focus on the use of natural educational environments, such as community colleges, trade settings, and universities as sites for educational interventions rather than artificial settings, such as sheltered or day treatment settings.

Developing Self-Awareness and Insight

Another relevant finding from research in psychology is that developing self-awareness and insight can lead to behavior change. A key focus of early counseling research was insight learning, or understanding how cause and effect relationships impact learning and problem-solving (Sternberg & Davidson, 1996) Within the context of mental health problems, research has investigated the importance of developing self-awareness and recognition of one’s problem and effects on daily life and interactions (Shad, Keshavan, Tamminga, Cullum, & David, 2007). Self-awareness theory in psychology has included descriptions of this quality as the ability to introspect and contrast current behavior with internal values (Duval, 2001). This literature has indicated that self-awareness contributes to important cognitive processes such as memory and processing speed (Demetriou & Kazi, 2001).

Research related to psychiatric disabilities has also identified the importance of self-awareness and insight. Awareness of symptoms has been identified as essential to symptom management (Shad et al., 2007). Lack of insight and awareness of symptoms in schizophrenia in particular has been linked to problems with treatment utilization, functioning, and involuntary hospitalizations (Ascher-Svanum et al., 2006; Dickerson, Boronow, Ringel, & Parente, 1997; Kelly et al., 2004; Shad et al., 2007). In addition, emotional awareness in oneself and others can enhance social functioning, quality of life, and social satisfaction (Baslet, Termini, & Herbener, 2009).

Related to the concept of self-awareness is insight in mental health treatment. While definitions of insight have ranged across therapeutic orientations, insight is broadly understood as self-awareness and understanding of one’s psychiatric problems that promotes treatment effectiveness (Goldberg, Green-Paden, Lehman, & Gold, 2001; Greenfeld, Strauss, Bowers, & Mandelkern, 1989). Greenfeld and colleagues (1989) suggested a number of dimensions to insight for individuals with serious mental illness, including views about symptoms, existence of illness, etiology, vulnerability to recurrence, and treatment value. Others have defined insight for individuals with mental illness to include similar dimensions, including awareness of the disorder, social consequences, need for treatment, symptoms, and attribution of symptoms to disorder (Mintz, Dobson, & Romney, 2003).

Of particular interest to policy makers and practitioners should be those initiatives to facilitate people’s own insight about their readiness to change (Cohen, Anthony, & Farkas, 1997; Prochaska, DiClemente, & Norcross, 1992). For people with severe mental illnesses, this insight relates to their understanding the commitment and capacity needed to change from a patient role to that of a citizen (Gamble, Abate, Seibold, Wenzel, & Ducharme, 2011; Rogers et al., 2001). Without first intervening to help people develop their insight about their readiness to change (i.e., to become an employee, spouse, neighbor, or student, etc.), program resources might be spent unwisely on people who are not committed to a particular change (Farkas, Sullivan Soydan, & Gagne, 2000). For example, unsuccessful attempts to help people become employed and end social security as a primary source of income (Russinova et al., 2013) may in part be due to people’s lack of understanding about what it takes to make that change. There must be time and resources focused on assessing and developing people’s self-determined readiness to change if resources are to be wisely designed and used.

Providing Support

For a number of decades, behavioral sciences research has emphasized the importance of social support in promoting mental health. For example, research-based theorists have suggested that social support may buffer individuals from the negative effects of stress, and may be beneficial even outside of times of distress (Cohen & Wills, 1985). Social support can positively impact coping, evaluation of stressors, self-efficacy, and problem-solving (Cohen, Underwood, & Gottlieb, 2000). Mental health services research has indicated that increased social support has been found to contribute to reduced hospitalizations, increased resource access, increased residential stability, and boost in mood (Albert, Becker, McCrone, & Thornicroft, 1998; Calsyn & Winter, 2002; Johnson, Meyer, Winett, & Small, 2000; Lam & Rosenheck, 1999). Perceived social support has thus been associated with a sense of greater life satisfaction, enhanced coping with stressors, and employment outcomes, and was predictive of fewer psychiatric symptoms (Rogers, Anthony, & Lyass, 2004).

Providing support to maximize functioning and goal acquisition in various community roles has become an important component of rehabilitation counseling interventions (Rogers et al., 2004). In addition, consistent with the research on support provision, support provided by one’s own peers has been increasingly emphasized in community programs and has been identified as effective in maximizing empowerment and facilitating recovery (Schutt & Rogers, 2009). Furthermore, peer support has been found to be helpful in decreasing social isolation and avoiding prejudices that can be encountered from receiving support in traditional mental health settings (Davidson et al., 1999; Schutt & Rogers, 2009). Also, peer support can further boost functioning (Yanos, Primavera, & Knight, 2001), and extend and diversify the social support network of people in recovery (Solomon, 2004).

Despite the previously reported myths surrounding skill interventions, in the past policymakers and rehabilitation counselors have historically devoted relatively more attention to skill development interventions than supportive interventions. The strategy for improving role functioning was focused on skill development, not support development (Anthony, 1979). Now, however, the research on support has shown that the provision of individual support can improve role functioning. Currently on a program level, programmatic interventions labeled as supported employment, supported housing, and supported education have been developed based partially on the evidence which shows the power of support in increasing role performance. Concurrently, based in part on the evidence base for support provision, policymakers can make a strong empirical and economic case for the further expansion of peer support initiatives.

Conclusion

Current evidence-based practice initiatives can be broadened to incorporate the notion of evidence-based helping processes that are fundamental to psychological growth and change. Much of the evidence base with respect to the helping processes originated decades ago in psychology research. This process research has at times been overlooked, and these processes are not always controlled in existing evidence-based practice research or identified. This review of helping process literature included levels of evidence generated by randomized clinical trials and research syntheses, as well as quasi-experimental, pre–post, and correlational designs. By combining the “people-first” principle with the knowledge base of relevant behavioral sciences research, as well as the developing field of mental health services research, certain evidence-based helping processes emerge as critical ingredients, which cut across many of the evidence-based practices. Moreover, this expansion of the evidence base encourages a public health perspective on mental health services (Anthony & Ashcraft, 2010), which suggests outcomes beyond symptom reduction, such as employment, housing, self-esteem and empowerment, and interventions much broader than treatment.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was funded by the National Institute of Disability and Rehabilitation Research (NIDRR) Advanced Rehabilitation Research Training Program in Psychiatric Rehabilitation CFDA Number 84.133P.

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