Recovery Programs for People With Mental Illness in Taiwan: A Feasibility Study

Participants

Study eligibility criteria were as follows: having a diagnosis of mental illness, being age 20 yr or older, living in the community, receiving services from the collaborating agency, and being able to participate in a recovery group and follow the group rules. People who could not fill out the scales independently were excluded.

Intervention

We designed a recovery group tailored to Taiwanese people with mental illness that was based on the PTR program (Ridgway et al., 2002) and mental health recovery literature (Davidson et al., 2005; Ridgway, 2001). The group gathered for a 1-hr session once a week for 18 wk. The curriculum included two phases. In the first phase (recovery profile), the main objective was to introduce the concept of recovery, including hope, empowerment, taking responsibility, self-redefinition, meaningful activities, and personal strengths. In the second phase (recovery plan), the main objective was to encourage participants to begin their recovery journey, including discussing published recovery stories, setting and executing recovery plans, and writing their own recovery stories. During the development process, participants were invited to offer suggestions about the group’s implementation in the last session of each phase.

On the basis of participants’ feedback, we added recovery stories and role exploration to our curriculum. Given participants’ unfamiliarity with the concept of recovery, the group spent the first phase learning about the concept itself. Many participants, however, still expressed frustration with understanding the concept, saying it was abstract, and demanding more examples to facilitate their understanding. Therefore, in the second phase, one indigenous recovery story was provided every week for participants to read at home and discuss with peers at the start of the next session.

Along with being introduced to the concept of recovery, many participants learned of concept of self-redefinition for the first time and realized its importance. Self-redefinition stresses that mental illness is only part, not all, of a person. People with mental illness should not focus on the patient role while neglecting other important roles and personal strengths (Jacobson & Greenley, 2001; Ridgway, 2001). To help participants further understand this concept, we added role exploration, which is not included in PTR, to the second-phase curriculum. We used the Role Checklist (Liu et al., 2004; Oakley et al., 1986) to help participants identify their past, present, and desired future roles. Then, to serve as a basis for their formulation of recovery goals, we discussed capabilities and occupations for their desired roles.

Because participants’ language was Mandarin, they could not read the PTR curriculum. Therefore, authors Chang and Su, who were familiar with mental health recovery concepts, translated the main titles or themes of each chapter of the PTR workbook and some forms or scales for course practice or homework and then designed a Chinese-language manual. The group content was taught by a senior occupational therapist (Su). Participants were required to complete weekly homework assignments that were based on session content. Group topics are listed in Appendix A. A supervisor met with the group leader after every session to confirm the accuracy of the information delivered.

Instruments

Data Collection

The study was approved by the institutional review board of National Cheng Kung University Hospital (No. A-ER-106–245). The recovery group was conducted at a community psychiatric rehabilitation center in southern Taiwan. The staff of the collaborating agency assisted in recruitment; participants attended the group after informed consent was obtained. The recovery group had two cohorts; the first cohort consisted of 10 participants, and the second cohort consisted of 14 participants. Participants filled out the SRS in the first class. At the end of each phase of the curriculum, participants filled out the SRS and course assessment and then participated in a 30-min discussion. The discussion included two parts: recovery stage change experiences and course suggestions. Discussions were recorded and transcribed.

Data Analysis

We collected both quantitative and qualitative data. IBM SPSS Statistics (Version 20; IBM Corp., Armonk, NY) was used for descriptive statistical analysis. We also calculated the effect size estimate, r, by dividing the z score by the square root of the number of total observations. We considered r = .10 a small effect; r = .30, a medium effect; and r = .50, a large effect (Cohen, 1988). The feasibility of the recovery group was evaluated by means of course questionnaires and qualitative data, including course feedback and course discussion transcripts. The corresponding author (Su) coded the qualitative data. The first author (Chang) reviewed the coding and discussed any disagreements with the corresponding author until consensus was reached.

Participants

Of the 24 study participants, 75% were women; 54% had been diagnosed with schizophrenia, and 42% had been diagnosed with bipolar disorder; 71% were single; 75% had a college or higher education; and 83% engaged in supported employment. The majority were at Recovery Stage 3 (42%) or Recovery Stage 4 (29%), according to the pretest SRS. Participants’ mean age was 43.21 yr (standard deviation [SD] = 8.37; range = 27–59), and the average attendance rate was 93% (SD = 0.10; range = 63%–100%; Table 1). Three participants were excluded from analysis as a result of incomplete posttest data.

Stages of Recovery Scale

We found that participants who were at Stage 4 at pretest had performance differences from participants at other stages, so we divided the participants into two subgroups (Stage 1–3 group and Stage 4 group) on the basis of their pretest recovery status scores. The two subgroups had no significant differences in gender, age, or diagnosis. They tended to perform differently on the SRS (Figure 1); the Stage 1–3 group scored higher at the end of the first-phase curriculum but had almost no change at posttest compared with the Stage 4 group, which tended to score slightly lower, with posttest scores still within the range of Stage 4 (>120). In addition, we found medium to large effect sizes (i.e., .30 ≤ r < .50) for Social Functioning/Role Performance scores for all participants and for SRS total scores, Disability Management scores, and Social Functioning/Role Performance scores for the Stage 1–3 group (Table 2).

OPEN IN VIEWER

Figure 1.

Total scores on the Stages of Recovery Scale at pretest, midterm, and posttest for the Stage 1–3 group and the Stage 4 group.

Course Questionnaire

We merged disagree and strongly disagree responses into “disagree” and agree and strongly agree responses into “agree” to document overall agreement with each item (Table 3). Total mean scores for first- and second-phase course questionnaires were 4.37 (SD = 0.52) and 4.29 (SD = 0.59), respectively, showing participants’ high identification with the group. In general, more than 90% of the participants were satisfied with the group, with the majority of participants believing that the manual and homework were helpful to their learning, although the item “I can memorize key points of courses ” had lower agreement (69.6% for Phase 1; 72.7% for Phase 2). With respect to items specific to each phase, nearly all participants (87.5%–100%) in the first phase agreed that the group helped them understand recovery-related concepts. For the second phase, the majority reported that recovery stories and writing their own stories were positive and helped them to understand and accept themselves (87.0% and 95.0%, respectively).

Qualitative Data

Three themes emerged from the qualitative data: recovery stage reflection, course suggestion, and recovery group impact. Regarding recovery stage reflection, participants reported different experiences. Some participants felt more positively about themselves, some had difficulty improving their recovery stages, and some described changes in their thoughts about recovery during the intervention:

As regards course suggestion, participants had two main concerns. Some had difficulty understanding the concept of recovery. Some suggested adding content, such as recovery stories and the meaning of self-redefinition:

Recovery group impact was mainly positive. Participants stated that participation in the group helped them change their perception and increase their acceptance of the disease: