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Abstract

Objective: The purpose of this article is to define the characteristics of effective support in community mental health settings for patients with serious and persistent mental illness.

Method: A broad literature providing empirical evidence on competent caregiver behaviours and styles is selectively reviewed. Relevant findings from family caregiver research and studies of social environments that enhance skill development in people with intellectual disabilities are incorporated, within a cognitive-behavioural framework.

Results: Six important domains are identified which represent positive caregiver styles: acceptance, creating a positive atmosphere, expectations of change, responsiveness, normalisation and educativeness.

Conclusion: The characteristics hypothesised to be critical for caregivers and support workers are defined in a general way that can allow for individualisation according to the goals of the programs and the cultural priorities of staff and patients. Further empirical validation of these characteristics would enable community mental health services to provide more specialised clinical treatments.

Keywords

caregivers cognitive-behavioural theory community mental health residential treatment

With the final stages of deinstitutionalisation now in place, and most of Australasia's long-term psychiatric institutions closed or closing, a diversity of community-based residential and day services have assumed much of the responsibility for the day-to-day care of individuals with persistent and serious mental illness (PSMI) [1]. In these new settings, direct-care staff, also termed support workers, play a crucial role in patients' quality of life and general progress towards mental health. Patients have been found to accord more value to their relationship with their case manager than to structural aspects of their care program [2], and various patient ratings of the patient-caregiver alliance (e.g. understanding, criticism) are predictive of hospitalisation [3].

Currently there is a paucity of information on the support staff behaviours most habilitative for patients with PSMI, or more broadly speaking, the critical elements of an effective social climate for a community mental health setting. However, certain generalisations should be possible from extensive suggestive evidence from the domain of psychological therapies. Given the wide variation in psychological therapies, it might be simpler to limit the derived principles to those therapies with a common theoretical focus. So, we could reframe the question and ask: According to the theoretical tenets of cognitive-behaviour therapy, what would be the ideal therapeutic environment for a community mental health setting?

In seeking to answer this question from a cognitive-behavioural perspective, of significance is the behavioural work carried out in the area of intellectual disabilities known as the ‘non-aversive’ approach to challenging behaviour [4] or ‘positive behavioural support’ [5]. It is also possible to extrapolate from treatment-outcome studies of less severe disorders, from research on other caregiving relationships such as parenting and from family systems research. Drawing from these various sources, six principles are posited to be of significance to the provision of effective support. In the remainder of this paper we will present some of the supporting data and arguments in favour of these ‘best practices’. These six are not claimed to represent an exhaustive list of elements necessary for effective support. Furthermore, although described separately, they are not isolated dimensions, but instead interact to provide a context for therapeutic change. Finally, although evidence for each principle is found within cognitive-behaviour theory, they are certainly not unique to this domain and have been endorsed within other therapies (e.g. [6]).

Rationale and empirical support

Principle one: acceptance

Behaviour therapy has begun to focus on the importance of acceptance as a background condition for interventions in various clinical problems that rely on an effective relationship between patient and therapist [7]. Of special relevance for the present discussion is Linehan's [8] empirically validated model for treating borderline personality disorder. While an acceptance of the reality of emotional experience is something to be fostered in patients, Linehan has also emphasised the critical need for the therapist to convey non-judgemental validation of the patient's feelings [9]. Acceptance thus refers not to unconditional liking or disliking of the patient by caregivers, but to experiencing patients as they are. For example, this may mean accepting patients' expressions of negative emotions and resisting the urge to terminate such events. Often when a patient is overtly distressed or angry, staff efforts are immediately directed at alleviating the display of these emotions, rather than ‘experiencing the moment’ and not feeling the need to control or direct the patient's experience.

Although research on expressed emotion is only indirectly related to this model due to that research's focus on family members, professional caregivers, too, have close personal and somewhat supervisory relationships with their patients and, hence, this research is of relevance. Caregivers' positive, non-critical affect, which is not overly involved with the patient, has repeatedly been shown to be important for favourable long-term outcomes for individuals with PSMI. A significant inverse relationship has been shown between level of warmth, as assessed by spontaneity, tone of voice, empathy, and interest in the patient, and relapse rate in schizophrenia [10,11]. A meta-analysis of research on the relationship between expressed emotion and relapse in schizophrenia found a positive relationship between these two variables in 24 of 27 published studies, with higher levels of criticism, hostility and emotional over-involvement associated with greater rates of re-lapse [12].

The importance of affect to patient outcomes has received support from studies of other clinical groups. Although there are many differences between parenting adolescents and caring for adults with serious mental illness, a common feature is the dual role of encouraging autonomy, while remaining supportive of the individual. Positive affect, regardless of the operational definition employed, is associated with a wide range of positive adjustment outcomes for adolescents, whereas parental hostility consistently predicts unfavourable developmental outcomes [13].

It appears that the cultural context impacts upon the expression and interpretation of positive affect. Expression of criticism, hostility and emotional over-involvement (i.e. high-expressed emotion) is rare in Indian families and Spanish-speaking Mexican-American families of individuals with schizophrenia [14,15]. Furthermore, Indian relatives frequently expressed criticism and warmth simultaneously, contrasting markedly with British populations where these two expressions are typically mutually exclusive. Patients' perceptions of their relatives' expressions also appear to be different in ethnic minority populations. Concordance between patients' perceptions of their relatives' attitudes and a measure of expressed emotion was high for Caucasian families and low for ethnic minority group families [16]. Given such findings, we assume that emotional expression in Maori, Aboriginal, and other minority cultural groups within Australasia needs to be explored, to clarify whether the expression and interpretation of affect differs within our cultural context.

Principle two: positive atmosphere

Atmosphere variables have been studied extensively in ward contexts, and cover a wide range of concepts such as degree of patient autonomy, warmth and friendliness, flexibility of staff, fairness, emphasis on physical characteristics such as neatness, and tolerance for eccentric behaviours [17,18]. Essentially atmosphere refers both to the ‘feel’ of a setting upon entry and to patients' subjective experiences of the environment [19].

Atmosphere is especially important in community mental health settings due to the particular vulnerability to stress of individuals with PSMI and the role that specific negative environmental events often play in eliciting negative emotional responses, such as anxiety, depression, and hostility. Given the vast range of triggers and their differential impact on individual patients, the presumed optimal way to train staff is to increase their awareness of the entire concept of stimuli as triggers, and to encourage vigilance to possible precipitating events or antecedents [4]. It is not expected that patients should always be insulated from stressful situations, since these will be encountered a great deal in the real world. However, once staff better understand the role of triggers, they can turn their attention to identifying the triggers associated with the symptoms of individual patients and assist patients to develop strategies to cope effectively with these triggers. Only after this has occurred would it be proper to expect patients to respond appropriately to negative environmental events.

Principle three: expectations of change/incidental learning

There is clearly a tension between the concept of acceptance, which argues for the acceptability of the person as he or she is at the moment, and the concept of change, which implies that the person ought to be different in some way. With reference to patients with borderline personality disorder, Linehan [9] has emphasised that ‘a core tension in the conduct and process of psychotherapy is that between the acceptance and change strategies used by the therapist’ (p. 81). The expectations that one holds of individuals with PSMI are likely to shape one's responses towards these patients. Over recent decades there has been a shift from a traditional medical model of rehabilitation towards an empowerment approach, focusing on well-ness rather than illness, and competence versus impairment [20]. It is assumed that staff expectations of patient change will be communicated in a variety of different ways, such as in discussions of the patient's future goals.

The current model assumes that when expectations of change are fostered in community mental health settings, staff will encourage patients to engage in novel experiences. We know much about the circumstances fostering incidental learning, meaning those conditions that are not formally instructional but, nonetheless, provide learning opportunities. In child development, incidental learning occurs when adult caregivers create opportunities for, say, language learning, not by formal instruction, but through implicit strategies such as modelling language, talking at a level higher than the child's, and expecting the child to talk about his or her experiences. Similar opportunities can be provided by caregivers in community support roles, for instance by talking about their own experiences, giving patients information about opportunities in the community, or showing interest in their activities. Direct-care staff usually have a range of personal abilities (e.g. music, crafts, gardening, cooking, sports) and the spontaneous modelling of these for patients often occurs. We frequently see in community residential services how staff might pick up a guitar and soon the patients have learnt a new song, or staff may fix the toilet so that a participating patient now has a new domestic skill. When services provide an approximate match to the culture, background, interests, age and gender of the patients, then these spontaneous learning opportunities can result in meaningful personal development for patients.

Principle four: responsiveness

A large body of theory and data has proposed that emotional and behavioural reactions to events are derived from causal beliefs about these events [21–23]. For example, persons suffering various physical problems (e.g. blindness, cancer, paraplegia) were seen as not responsible for these conditions and roused high help-giving motivation from others. By contrast, individuals with primarily behavioural and mental difficulties were typically held responsible for these problems and evoked little pity and low help-giving motivation from others [24]. Hence, the attributions and expectations made by support workers about patients' behaviour are likely to be significant determinants of their responses towards patients.

As has been noted, individuals living in family environments typified by high levels of hostility, criticism and emotional overinvolvement (i.e. high-expressed emotion) are significantly more at risk for relapse than persons who live with families who do not display these behaviours [25]. An attributional model of expressed emotion was developed by Hooley [26] to explain the development and maintenance of high- and low-expressed emotion attitudes. This model proposes that family members will be more tolerant of undesirable behaviour attributed to illness and to factors outside of the patient's control and more critical of undesirable behaviour perceived to be within the control of the individual. It was also hypothesised that positive symptoms (e.g. hallucinations) would be seen as less controllable than either negative symptoms (e.g. anhedonia), or behaviours indicating poor impulse control [27]. These attributional dimensions have been evidenced in studies on relatives of patients with PSMI, with high-expressed emotion families making more personal and controllable attributions for patients' undesirable behaviour than low-expressed emotion families, particularly with respect to antisocial behaviour and negative symptomology [28,29]. This model has shown cross-cultural relevance, with similar findings in research populations in England [29], Australia [30], United States [31] and in a Mexican-American sample [32].

From these studies it can be surmised that personal and volitional attributions for a patient's behaviour are more likely to result in critical and hostile responses, which places the patient at higher risk of relapse. However, equally unhelpful for rehabilitation purposes may be attributions for all behaviour as involuntary and illness-related. Weisman et al. [32] suggested that it is the excessiveness of the controllability perception that it is detrimental, rather than the existence of this perception. Hence, effective support-worker interactions would seem to require a balance between making controllable or intentional attributions for behaviour, which are likely to summon punitive responses, and uncontrollable or illness-related attributions, which conflict with rehabilitative goals of patient competence and autonomy. Attributions which focus upon (i) environmental contingencies and/or functions of behaviour, and (ii) the patient's previous learning experiences would appear to strike this balance, by providing a non-punitive explanation of the patient's actions and by viewing new learning opportunities as the key ingredient for behaviour change.

Principle five: normalisation

Although the community care model promotes community integration for individuals with PSMI, the stigma attached to mental illness often means that these individuals are quite isolated from the typical activities of community life. Nonetheless, services can do much to encourage community integration. For example, efforts can be made to form positive relationships with neighbours and to avoid obvious signs of being a mental health facility. Some features that may reinforce social isolation can be quite subtle, for example, a group mini-van excursion for patients, whereby patients may be viewed as a homogeneous population by community members, as opposed to patient participation in activities incorporating a cross-section of people from the community.

One of the most important features of this aspect of staff behaviour is the degree to which staff are able to encourage patients to develop typical social relationships with people completely outside the formal mental health system. Again, the analogy with supervising typical teenagers is apt. If the patient meets someone with whom they would like to have a romantic relationship, does the facility enable that patient to bring a friend back to the house, allow them to sleep over, and make sure that the telephone is available for chatting? Slightly more complex is the role played by staff in helping patients make prudent decisions: is this person really suitable as a friend, are they safe, does the patient know about sexual protection and birth control? The extent to which such matters are openly discussed will have impacts on the ability of the service to foster social relationships. Oddly enough, cognitive-behavioural approaches have emphasised the importance of teaching people with PSMI specific social skills [33], but have not considered the opportunities available for patients to meet, relate to, and form meaningful friendships with other people [34].

A social environment encouraging normalisation would strongly support patient empowerment. Research from various perspectives has demonstrated that individuals who perceive that they are the authors of their own behaviour are better adjusted than people who act for external or controlled reasons [35–37]. Democratic decision making within the setting would be a key criterion for normalisation, with patient consultation on all policy matters within the setting and in the design of new rules and routines. We have repeatedly observed staff reluctance to establish such systems due to the perception that some loss of control over the environment will ensue. Given that this is the precise goal, it might be useful to make parallels between this process and other cultural practices. In New Zealand, within Maori culture, it would be fully expected that decision making would be based on group consensus, usually during formal discussion sessions called hui. Similar processes could be adopted as a decision-making model within the community service setting.

Principle six: educative functions

A major element of all behavioural programming has been the responsibility of direct-care staff to teach new skills to patients, especially self-help and social skills. There is overwhelming evidence that such skill development can be achieved and that patients benefit considerably from opportunities that give them new competencies [38–40]. Rather than attempt to review this large body of evidence, we will merely highlight certain issues. Our general position is that formal instructional programs should be designed and implemented only by professional-level staff, with care-givers primarily responsible for the generalisation [41], modelling and facilitation of new competencies.

Formal teaching should be outside the home

In typical family homes we recognise the role of parents in terms of teaching children many skills, but accept that the formal teaching of academic skills is best left to trained teachers in formal educational settings. Though position descriptions of direct-care staff may contain elements of the teacher role, it is important not to conceptualise them as formal teachers due to the dual relationships created when this concept is taken too far. The patient's home is not a school or a technical college, and if specific skills are required it would be more ecologically valid to arrange attendance at an educational setting [42]. Note, too, that the teacher role can justify a more controlling, obedience-requiring relationship than would be desirable for support staff.

Teaching positive alternatives

Given the enormous number of possible skills that could be taught to patients, some principles are needed to determine priorities. One of the best principles is that symptomatic behaviours, and especially challenging behaviours such as aggressive, self-injurious or disruptive behaviours, typically reveal deficits in more-appropriate, alternative behaviour, especially communication skills [43]. In other words, symptomatic behaviours are not simply inappropriate behaviours that must be controlled and eliminated, but give clues as to the patient's needs and indicate areas in which the patient either lacks skills or cannot access them for some reason.

It is important to ensure that if new skills have been specified as alternative behaviours, then the environment must be especially responsive to these new behaviours. If, for example, a patient is encouraged to express feelings rather than be aggressive, then it is critical that the social environment listens to, and responds appropriately to, initial attempts by the patient to express these feelings. Positive alternatives must be as functional (or more so) in the social environment as the undesirable behaviour. Thus, while it would not be expected of direct-care staff to design and implement formal instruction in new adaptive behaviours, it should be expected that they will be attentive to, and reinforce, these new skills as they emerge.

Patient choice

The above issue relates closely to the need to emphasise patient choice when imposing a formal instructional program on patients. There has always been a danger in behavioural support programs that well-meaning staff will emphasise functional skill development programs to the exclusion of other activities, such as cultural learning experiences, that enhance the patient's cultural identity or fun-related activities, such as learning a new hobby or leisure pursuit. This creates a program atmosphere that is too serious and devoid of other important learning opportunities.

Caregiver characteristics

In principle, all of the aforementioned elements of effective support could be attained through intensive training and supervision. This assumption is rather like that of the behavioural parenting literature, where it is assumed that parenting behaviours can be made more appropriate by means of educational groups and other learning opportunities. However, it is difficult to teach parents more effective skills if they have other difficulties, such as economic stress, social disadvantage or depression. Likewise, it is necessary to identify the role that the personal coping resources of direct-care staff are likely play in the implementation of practices consistent with the principles of an effective therapeutic environment.

According to Greenley's [44] social conceptualisation of emotional expression, caregivers experience anxiety and fear when they perceive that a situation overwhelms their coping abilities, resulting in attempts to control the patient through criticism and overinvolvement. Relatives of individuals with mental illness demonstrated more hostility when facing symptoms that they doubted their ability to cope with or control [45]. Interventions to teach high-expressed emotion relatives more appropriate ways of coping with stressful situations have shown a significant reduction in rates of criticism, emotional overinvolvement and hostility, and decreased patient relapse rates [46]. Low levels of perceived caregiving burden were associated with parental reports of intimacy, acceptance, respect and enjoyment with an adult offspring with mental illness, whereas higher levels of care-giving burden were positively correlated with levels of perceived conflict in the relationship [47].

Certain coping strategies have been linked to positive and negative responses towards others in stressful situations. In empirical testing of Chwalisz's [48] perceived stress model of caregiver burden, it was concluded that attempts to change something about the caregiving situation, known as problem-focused coping, may lead to caregivers appraising their plight as less stressful than efforts focused on ameliorating negative emotions, termed emotion-focused coping. This pattern has been replicated in other areas of study, with emotion-focused coping significantly associated with higher burnout scores among nurses in rehabilitation units [49].

Support from others has been found to be an important component to coping effectively with the demands of caregiving, consistent with the ‘buffering hypothesis’ notion of social support [50]. In a recent study of caregivers of persons with chronic mental illness [51], caregivers' overall instrumental and emotional support was found to be the strongest predictor for caregiver depressive symptomatology. Similarly, Chwalisz [48] found a significant inverse relationship between overall social support and perceived stress in spouse caregivers of persons with brain injuries. This highlights the importance of ensuring adequate emotional and instrumental support for direct-care staff from colleagues, agency management and allied mental health services.

The culture of the caregiver may influence perceived caregiving burden and coping efficacy. It has been suggested that traditional ethnic groups may conceptualise and respond to mental illness in a less stigmatising and more tolerant manner, thereby decreasing the stress of caregiving [52]. Consistent with this proposal is Howritz and Reinhard's [53] finding that African-American caregivers attached less stigma to serious mental illness than European-American caregivers, and perceptions of stigma were related to greater caregiving burden. Caregivers from African-American families tended to report less burden than white American and Hispanic families, which could not be accounted for by protective mechanisms such as social support, religious involvement and illness attributions [54]. To date, there has been little published research on Maori conceptualisations of mental illness. However, some small-scale studies, such as Bevan-Brown's [55] thesis on Maori views of intellectual disability, suggest that Maori understandings of, and attitudes towards, disability and illness may differ from Western conceptualisations.

In conclusion, confidence in one's coping abilities appears to be a crucial ingredient to the establishment of an effective therapeutic environment by direct-care staff. Coping efficacy appears to be a function of several factors, including use of problem-focused coping, the availability of support and cultural conceptualisations of mental illness.

Conclusions

So to return to the original question, What would an ideal therapeutic environment look like? In this paper we have proposed six broad areas of support staff competencies for patient care, the significance of which is indicated by many different sources of evidence. There would be an atmosphere of acceptance, one that is tolerant, non-critical and in which the patient experiences comfort and security. Somewhat related, a positive atmosphere would be evident, that is, a congenial, non-authoritarian environment that would strive to minimise triggers to patient distress. Expectations that change is possible would be held by staff and would be reflected in learning opportunities offered to patients and positive reinforcement for small accomplishments. The environment would demonstrate responsiveness to patients' needs and feelings, by attending to the function of inappropriate behaviours and by providing positive corrective feedback. The climate would emphasise normalisation, by avoiding stigma, assisting patients to develop relationships outside of the mental health arena and ensuring democratic decision making within the setting. An effective setting would have an educative function, by teaching positive alternatives to inappropriate behaviours, emphasising patient choice in selection of formal learning programs and ensuring a wide range of learning opportunities for patients. Finally, critical to the creation and maintenance of such an environment would be effective coping by staff, fostered through use of problem-focused coping and access to support.

At this stage the delineation of an effective therapeutic environment has been largely at the general level. This is consistent with our position that these are styles of caregiving and that the exact responses derived from the areas suggested here should be tailored to the needs of individual patients, the characteristics of the setting and personal traits and cultures of staff members. Hence, these styles are represented by a wide variety of behaviours and responses. To facilitate transition from principle to practice, research in the New Zealand setting has recently piloted training materials to teach these general competencies to direct-care staff [56]. Once they are well versed in these, it is hoped that they will begin to examine their practice, patient-care plans, program rules, procedures and policies in light of these principles, and to make changes so as to more closely reflect an effective therapeutic environment.

In conclusion, the interactions of direct-care staff with patients proffer countless opportunities for social and emotional learning, and hence their role in patient habilitation is potentially enormous. To date, research seems to have paid little attention to how this potential can best be realised, with community settings often viewed as peripheral, rather than central, to treatment and direct-care staff typically positioned at the lower end of the mental health service hierarchy. It is hoped that the principles outlined in this paper will encourage further research on the design of effective community-based care and will promote increased recognition of direct-care staff's role in patient habilitation.

Footnotes

Acknowledgements

Preparation of this paper was made possible by a grant from the Health Research Council of New Zealand (Rangahaua Kaitautoko; Ian Evans and Averil Herbert, co-Principal Investigators), which is acknowledged with thanks. No official endorsement by the Health Research Council of the opinions expressed should be inferred.

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Defining Effective Community Support for Long-Term Psychiatric Patients According to Behavioural Principles