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Exploring the meaning of best practice: A discussion on the way client-centred psychosocial rehabilitation services might address the needs of Australian veterans in the future.
Francine T. Hanley,1 Lynda R. Matthews2 and Virginia J. Lewis1,3 1 Australian Institute for Primary Care and Ageing, Faculty of Health Sciences, La Trobe University, Australia 2 Ageing, Work and Health Research Unit, Faculty of Health Sciences, University of Sydney, Australia 3 Australian Centre for Posttraumatic Mental Health, University of Melbourne, Australia
This is the author’s version of the work. It is posted here by permission of Australian Academic Press for personal use, not for redistribution. The definitive version was published in The International Journal of Disability Management Research, 2011, Volume 6, pages 10–21. DOI 10.1375/jdmr.6.1.10 http://dx.doi.org/10.1375/jdmr.6.1.10
Abstract This paper presents a summary of ten priorities for the delivery of best practices in psychosocial rehabilitation relevant to the Australian veteran population. The first section interrogates the empirical principles characteristically identified with best practices before presenting an alternative, heuristic framework organised by three reference points and informed by principles of efficacy, external validity, and the meaning of efficacy in the context of parity. The paper presents the strategy used in reviewing the literature, before presenting the findings according to ten key priorities. The ten priorities are described in the context of the literature informing them and are set out with regard to the centrality of the client-centred service model in the design and delivery of pertinent and effective services into the future.
The aim of this paper is to present the findings of a literature review undertaken for the Australian Department of Veterans Affairs (DVA). The brief for that review was to develop a document on best practices in psychosocial rehabilitation relevant to the Australian veteran population and their families. Psychosocial rehabilitation (PSR) is a comprehensive service design that is characterised by the provision of a range of social and therapeutic service options developed in the context of clients’ self-determined goals and preferences. Informed by the recovery movement (Anthony, 2000), psychosocial rehabilitation integrates health and a range of social support services in order to target the needs of people recovering from mental illness. It is characterised by a client-centred approach and, in as much, aims to deliver services that acknowledge the expertise of the client; who participates in the formulation of their own care plan toward recovery (National Ageing Research Institute, 2006). National policy in Australia now recognises the psychosocial rehabilitation model as a means to support the mental health of the wider community through concepts like empowerment and choice within the context of good clinical care (Commonwealth of Australia, 2009b). There are unique challenges to be addressed in providing access to psychosocial rehabilitation services in Australia. These challenges are broadly encompassed by three factors that affect the delivery of health care in Australia more broadly, they include: geographical distance; population density and; workforce shortages (Bonner, Pryor, Crockett, Pope, & Beecham, 2009; National Health Workforce Taskforce, 2009). The first two factors interact closely. By far, the greater proportion of the national population and the availability of health care are to be found in large cities and regional communities. Rural and remote communities have limited access to both primary care and allied health care services. All areas of Australia are affected by health workforce shortages, but these shortages are being felt more acutely in rural and remote regions where the former two factors noted above add to
the challenge of delivering services (National Health and Hospitals Reform Commission, 2009). This very particular set of challenges requires solutions that address the availability of services nationally within a framework that targets best practice models of care according to the resources available. Best practices and psychosocial rehabilitation Best practices in psychosocial rehabilitation represent the gold standard for the design and delivery of client-centred support and therapeutic services. The academic literature identifies the standard for best practices in psychosocial rehabilitation by way of the same evidence-based criteria applied in the physical sciences. Thus, best practices in psychosocial rehabilitation are regularly defined according to one of the following: the efficacy of an intervention or treatment model against the backdrop of statistical power (Bond, Drake, & Becker, 2008; Dixon, et al., 2001); level of rigor applied in the implementation of a treatment or service model that ensures consistency across different settings (Corbiere, Bond, Goldner, & Ptasinski, 2005; Kennedy, et al., 2003; McHugo, et al., 2007); and the systematic analysis of the research literature selected according to evidence-based criteria to determine consensus with respect to the efficacy of treatments or service models in use (Compton, Bahora, Watson, & Oliva, 2008; Roberts, Kitchiner, Kenardy, & Bisson, 2009; Van Citters & Bartels, 2004). The evidence-based approach to best practices has been widely adopted by the health and psychological sciences. The strict empirical standards defined by the evidencebased approach are important when evaluating ‘what works’ and ‘how things work’ because they permit the magnification of valid evidence, but the disadvantage of delimiting the parameters for best practices in psychosocial rehabilitation to those applied in the physical sciences is that implementation will require the replication of strict experimental-like conditions to ensure efficacy. Criticism of the evidenced-based paradigm within the
rehabilitation literature has thus noted that strict parameters come into question where client needs are complex (Bruce & Sanderson, 2005; Murphy, King, & Ollendick, 2007) or where the pathway to recovery is unique to the individual (Anthony, Rogers, & Farkas, 2003). Identifying best practices that address the challenge of complexity When planning to review best practices in psychosocial rehabilitation for the Australian context, the parameters needed for a gold standard came into question very early. Firstly, a range of research reports released during 2009 gave shape to a social and geographical context that would have a direct affect on any discussion around service effectiveness in Australia. There was the release of: 1) a review of mental health services addressing the needs of the Australian Defence Forces (ADF) which highlighted questions about the health and mental health needs of members, former members and their families (Dunt, 2009); 2) an empirical study on the barriers affecting the delivery of rehabilitation services to veteran populations that identified a number of challenges affecting the quality of those services (Australian Centre for Posttraumatic Mental Health, 2009); 3) the Fourth National Mental Health Plan (2009) which underlined and re-iterated the scope of the five priority areasi required to improve services in the community mental health sector (Commonwealth of Australia, 2009a), and finally; 4) the National Health and Hospitals Reform Commission report which pointed to the impact of geographical distance on the delivery of all forms of health services to rural and remote regions and to the significant gaps within the wider system for people with serious mental illness (Commonwealth of Australia, 2009b). Secondly, it was deemed important to take account of the emerging literature in psychosocial rehabilitation given the level of complexity and the challenges presented in the four reports described above. For example, the emerging literature had begun to identify the
importance of holistic approaches; where the treatments for physical wellbeing were brought into closer connection with treatments and services for mental wellbeing (Clark, Bair, Buckenmaier, Gironda, & Walker, 2007; Maguen, et al., 2007; O'Sullivan, Gilbert, & Ward, 2006). The academic literature from North America had brought attention to the importance of the ageing population in the design of psychosocial rehabilitation components (Van Citters & Bartels, 2004), and of the impact of recent military deployments on the mental health of returning service personnel (Rona, et al., 2009), including the specific needs of female returning personnel (Vogt, et al., 2006; Yano, et al., 2006). The strategy applied to the review of the literature is presented in Table 1. Insert Table 1 here. In consideration of the social, geographical and empirical context in which best practices would be delivered, the parameters for the gold standard were interrogated. The International Classification of Functioning Disability and Health (World Health Organisation, 2002a) informed this interrogation for its focus on contextual factors and the way the client interfaces with them (Elliot & Warren, 2007), and three points of reference were drafted as the basis for a heuristic framework. Thus, best practice was assigned to documents where: 1) approaches demonstrated efficacy according to statistical power; 2) models of service demonstrated efficacy within specific systems or contexts relevant to the needs of many current and former serving members of the ADF; and 3) models were inferred from theoretical frameworks aiming to ensure parity and/or equity across community populations. Reference point two above incorporated documents on topics pertaining to holistic pain management treatments (Sullivan, Adams, Tripp, & Stanish, 2008; Sullivan, Feuerstein, Gatchel, Linton, & Pransky, 2005; Sullivan, Ward, et al., 2005), peer support initiatives (Hebert, Rosenheck, Drebing, Young, & Armstrong, 2008), family services (Bowling & Sherman, 2008) and healthy lifestyle services for people with mental illness (Atlantis, Chow,
Kirby, & Singh, 2004; Callaghan, 2004; Otter & Currie, 2004) on the basis that such programs were beginning to demonstrate that they provided supplementary support to the efficacy of core components within psychosocial rehabilitation designs. Reference point three incorporated papers that addressed parity of access for groups such as: women returning from deployment (Goldzweig, Balekian, Rolón, Yano, & Shekelle, 2006); users of alcohol or other substances (Kerrigan, Kaough, Wilson, Wilson, & Bostick, 2004); people in need of housing services (Browne, Hemsley, & St. John, 2008; Chesters, Fletcher, & Jones, 2005; O'Connell, Kasprow, & Rosenheck, 2008); clients affiliated with particular age groups or cohorts within the veteran population (Milliken, Auchterlonie, & Hoge, 2007; Oslin, et al., 2003; Seal, Bertenthal, Miner, Sen, & Marmar, 2007) and; the needs of people likely to have regular or intermittent contact with psychosocial rehabilitation services across an extended period of time (Crawford, de Jonge, Freeman, & Weaver, 2004). The three points of reference supported the exploration and analysis of more than 300 articles and the development of a review of psychosocial rehabilitation services for veteran populations (Australian Centre for Posttraumatic Mental Health, 2009a). The narrative review was analysed inductively and summarised by 30 priorities, which were further refined into ten key priorities. The remainder of this paper describes these ten priorities in the context of the literature supporting them. Best practices in psychosocial rehabilitation for the Australian veteran population 1. Best practices in PSR are guided by the recovery movement. Recovery-oriented care is a client-centred service approach that assigns the client with the status of the central stakeholder in his or her own health and thus prioritises his or her needs, goals and preferences in designing and delivering services. Recovery-oriented rehabilitation focuses on informing clients properly about their options in order to enable
each individual to make better decisions about the direction of their own care and thereby aims to improve the social independence of each individual in the context of an ongoing link with case management and support. While recovery-oriented care emerged from the mental health sector, the Australian National Mental Health Plan 2003-2008 (Australian Health Ministers, 2003) brought its aims into greater focus with an emphasis on the importance of collaborative relationships between the service providers and consumers (i.e. client, their families or carers). It also underlined the need for service organisations to take a greater lead role in health promotion around mental health and for a greater commitment of resources to be made in order to improve the capacity of services to support the participation of clients and their families (or carers) within service organisations. 2. Best practices require an integrated approach Psychosocial rehabilitation is delivered by way of an integrated and multidisciplinary response to health and mental health care. An integrated system encompasses sustainable, collaborative relationships between hierarchical divisions of departmental sectors (vertically) and equally coactive relationships between distinct jurisdictions (horizontally). When seeking to introduce expertise-driven, network-based systems of service like vocational rehabilitation into large government organisations like the Department of Veterans Affairs, it is important to: (a) give close attention to all levels of the organisation, especially top leadership; (b) assign clear program objectives; (c) underline the investment proffered by training when conducted by experienced experts; (d) facilitate the creation of an open learning community within the organisation through multiple media; and (e) to provide structured programs with opportunities for performance measurement and regular feedback at both the program and client level (Resnick & Rosenheck, 2007).
Integrated service models also need to devise funding solutions for allocations serving the needs of individuals across a range of different sectors (i.e. like that between employment and mental health services). This has been shown to be especially important in the community based contexts where the implementation of evidence-based interventions have failed in the absence of integrated program designs that address the complexity associated with how resources are targeted and dispensed over time (Pratt, Van Citters, Mueser, & Bartels, 2008). Funding solutions thus need to be pooled or reallocated to reflect an integrated approach to service provision and thus ensure the viability of programs and the sustainability of relationships between collaborating sectors (Waghorn, Collister, Killackey, & Sherring, 2007). Last but not least, psychosocial rehabilitation is a multidisciplinary response to health care and mental health support. Multidisciplinary team rehabilitation is a coordinated approach, which aims for wrap-around services according to need and organises case review processes in the context of face to face team settings. Multidisciplinary service options also require service staff to have specialist knowledge and transferable skills (Drake, Becker, Bond, & Mueser, 2003), and that those skills be maintained locally by way of ongoing staff training or through brokerage with the community sector where pressures to parity may be present. Training solutions may include: (a) skills in assessment procedures and protocols; (b) crisis intervention strategies; (c) vocational rehabilitation; and (d) family support initiatives. The ICF framework (WHO, 2002) is especially well suited to multidisciplinary care contexts as it provides codes for addressing functional assessments and the applicability of assistive devices, treatment planning, treatment outcomes, program evaluations and quality assurance (Ustun, Chatterji, Bickenbach, Kostanjsek, & Schneider, 2003).
3. Best practices support clients across the continuum of care Best practices in psychosocial rehabilitation require a clearly articulated map of the continuum of care. In the Australian context, the continuum of care set out for mental health services has been described as having nine stages: (a) access; (b) entry; (c) assessment; (d) care planning; (e) care implementation; (f) care evaluation; (g) separation; (h) exit; and (i) reentry (Goh & Singh, 2005). A framework such as this lends itself to a more flexible approach to the delivery of services for individualised needs, as the entry point and pathway traversed across the service system can be recorded over time. A map of the continuum of care also supports service systems with multiple points of entry, and thereby the standardised use of intake procedures whether conducted person to person, by telephone, from a web-based interface, or if arriving by post (Mandersheid, 2007). A clearly mapped outline of the continuum of care also ensures that individuals can be promptly transferred from each point of entry to case management services (Drapalski, Milford, Goldberg, Brown, & Dixon, 2008) and accordingly to the most urgent and relevant services (Glynn, Drebing, & Penk, 2008). Rehabilitation services addressing different levels of need can also apply the continuum of care to establish clear pathways into and leading from crisis intervention services and early detection/intervention strategies, where the process of referral supporting clients should be conducted more proactively (Seal, et al., 2007). For example, primary care clinics play an important role in early intervention measures, for screening depression and in the prevention of suicide in veteran populations (Zilke, Morrison, Kirby, & Martin, 2006), and a map of the continuum of care can guide the referral system through its capacity to show links between stages in the service system and thereby between practitioners (Chappelle & Lumley, 2006). It has also been identified that positive outcomes in mental health service utilisation are associated with proactive referral processes by primary care physicians (Wong,
et al., 2009 ). The role of the primary care sector, therefore, should be closely evaluated when seeking to improve the efficiency and uptake of mental health services in populations where the initial problem may not be a mental health concern. 4. Best practices involve coordinated case management Coordinated case management services are essential to a client-centred approach to service planning and play a core role in maintaining the continuum of care. The barriers in access to best practices in psychosocial rehabilitation have been found to be associated with the personal and cognitive consequences of having a mental illness and with the concomitant difficulties clients can have in communicating their needs to providers (Drapalski, et al., 2008). Hence, the key responsibility of the case manager should be to ensure that the consequences of having a mental illness (i.e. symptoms or side effects) do not interfere with the client’s access to services or to his or her ability to articulate need. Strategies that aim for optimum outcomes from case management should address early intervention and prevention programs in addition to typical case management responsibilities. The veteran and military research literature contains only sparse comment on early intervention, although the need for a greater emphasis on primary prevention has been underlined in the context of the youngest serving members (Seal, et al., 2007). Case management services are well placed to coordinate the early detection of mental health need and, where veterans may evade access to mental health care, to make contact with partners or supportive family members; important contacts in the case management process (Milliken, et al., 2007). Where veterans receive treatment and rehabilitation services across multiple settings (Shay & Burris, 2008), primary care services have an important role to play in early intervention by liaising closely with case managers for individuals with depression or suicide risk (Kirchner, et al., 2008). Finally, linking veterans to diversified case management
arrangements such as telephone call consultations or other like services have been shown to be effective, particularly in the context of veteran populations of an older age and/or limited mobility, and with a diagnosis of depression or patterns of at-risk drinking (Oslin, et al., 2003). Case management programs also need to have strategies in place to ameliorate the propensity for veterans with serious mental illnesses to slip through the system undetected; especially where they are older or living in remote locations (McCarthy, et al., 2009). Policy thus needs to frame rehabilitation in a long term context and include service options that address acute mental health needs for veterans into their sixties (Mares & McGuire, 2000). Services developed specifically for the case management of older veterans in rural and remote areas have demonstrated the importance for comprehensive designs that include standardised assessments, coordinated care planning, and processes that ensure that older persons are given opportunities to communicate their needs adequately (Ritchie, et al., 2002). Defence discharge processes should initiate the case management process and direct each veteran to rehabilitation in a seamless way. Eligibility criteria for rehabilitation needs to be clearly defined and act to facilitate the formulation of pathways to care. The tasks of the case manager in this context should include: (a) comprehensive assessment; (b) care planning; (c) consumer facilitation through the system; (d) client advocacy; (e) coordination of services; and (f) re-evaluation of client progress (Zilke, et al., 2006). 5. Best practices address the vocational need of every client. A satisfying work life offers a sense of belonging and economic security as well as opportunities for a positive work climate, personal success and recognition (World Health Organisation, 2005). One of the central features of psychosocial rehabilitation is the provision of employment support services. These services should focus on providing individualised
care so that the consumer’s goals, abilities, difficulties and specific situation are taken into consideration throughout the process (Corrigan et al., 2008). Vocational programs that provide a range of rehabilitation interventions with demonstrated efficacy and program fidelity, and that address a range of vocational support needs ensures that consumers receive a well-defined program model with demonstrated effectiveness. Programs like the evidencebased supported employment approach of individual placement and support (IPS; Bond, 2004) and the Thresholds vocational program known as the diversified placement model (Koop et al., 2004) have demonstrated their applicability to the delivery of a sustained and individualised approach that fits well to the needs of veterans (Koop, et al., 2004; Rosenheck & Mares, 2007). Both these models have demonstrated their suitability for participants with complex needs and, IPS especially has demonstrated positive outcomes on long-term vocational outcomes (Bond, et al., 2008). Vocational services designed for veterans with a history of substance use also need close consideration, as substance use has been associated with homelessness and mental health conditions (Furlong, et al., 2002; Kerrigan, et al., 2004; LePage & Garcia-Rea, 2008); both significant barriers to gainful employment. Other barriers facing this highly disadvantaged veteran group include individual age, disability status, and drug of choice (Kerrigan, et al., 2004). The effectiveness of vocational rehabilitation to groups with very complex needs is likely to rely on the rigorous inclusion of supported housing and/or extended after-care services in a drug-free environment (Kerrigan, et al., 2004). Vocational support services to this population need to include focused assessment procedures that elicit very specific information about client need, and include a means to capture an understanding of the concrete barriers each person faces in obtaining employment. Organisations and employers also need to address any stigma and discrimination associated with mental illness within workplaces and ensure that challenges to the
reintegration of individuals at work are minimised (Kaufmann, 1993; Scheid, 2005). Specific workplace interventions would therefore include strategies that promote these two requirements, such as: (1) the development of an organisational culture that both encourages early disclosure of mental health conditions and supports rehabilitation at all levels as a valid intervention to work injury, (2) the education of employers and co-workers about mental illness and other persistent health conditions, and (3) the provision of timely and appropriate accommodations to support workers to maintain employment (Matthews, 2006; Muenchberger, Kendall, & Domalewski, 2006). National mental health employment policy reiterates much of these interventions (Mental Health Council of Australia, 2007). 6. Best practices address physical health and wellbeing. The role of regular exercise has been a neglected area in the rehabilitation field despite the fact that early indicators suggest that it improves mental health and well-being, reduces the negative effects of depression and anxiety and enhances cognitive functioning (Callaghan, 2004). People living with a psychiatric illness are known to suffer a higher burden of physical conditions when compared with age-matched people without a mental illness. For example, depression, anxiety, bipolar disorder and schizophrenia have been identified as significant risk factors in cardiac disease (Smith, et al., 2007; Sowden & Huffman, 2009), while regular exercise has been found to be positively associated with the reduction of symptoms in psychosis, depression and anxiety (O'Sullivan, et al., 2006). In a qualitative study of the experiences of a group of 14 Australian Vietnam veterans, including five who stated being diagnosed with PTSD, researchers described the positive effects that arose from a 40-week exercise programme tailored especially for them (Otter & Currie, 2004). The authors reported that the participants achieved physical benefit from the exercise, but additionally reported that the supportive interactions established through the
program provided a psychological sense of wellbeing when assessed using a self-reporting measure. Healthy lifestyle behaviours have also been identified as important in substance abstinence and studies have shown that veterans participating in more leisure, social and coping behaviours were less likely to relapse (LePage & Garcia-Rea, 2008). In contexts devoted to the rehabilitation of physical injury, rehabilitation treatments have shown greatest effectiveness when designed around comprehensive screening processes that elicit information on: (a) the complexity and severity of the injury; (b) the presence of posttraumatic stress disorder; (c) any pain-related psychosocial distress or mixed-pain conditions; (d) the geographical location/distance needed to travel to access rehabilitation; and (e) the amount of analgesic medication prescribed. Best practices in the rehabilitation of physical injuries have also been aligned to the level of consistency in: (a) the assessment procedures including that around pain outcomes; (b) psychosocial documentation; and (c) referral processes (Clark, Bair, Buckenmaier, Gironda, & Walker, 2007 ). 7. Best practices emphasise the role of psycho-education and health promotion. It was identified above that an overarching culture of stigma around mental illness in the ADF has impinged upon principles of parity in the delivery of mental health services to both current and former serving members of the ADF (Dunt, 2009). Research from the US on the delivery of rehabilitation to current serving military personnel has demonstrated also that clients with mental illnesses regularly experience structural and/or organisational barriers in getting access to pertinent and timely services. When combined with the social stigma often associated with having mental health problems, the barriers facing veterans and discharging personnel have been identified as a significant obstacle to the way each client approaches his or her needs assessment (Chappelle & Lumley, 2006; Pietrzak, Johnson, Goldstein, Malley, & Soutwick, 2009). Improved mental health literacy across all levels of the military hierarchy
and veteran services sector through psycho-education and health promotion is thereby essential in order to impart greater awareness to the military and veterans services work culture, to the family and to the social environments in which veterans live. Improving community awareness and acceptance around mental health and mental illness also has the capacity to improve the early detection of needs, which for veterans, are regularly expected to be declared in order to receive relevant and timely services (Stecker, Fortney, Hamilton, & Ajzen, 2007). Strategies designed to engage veterans and their families in psycho-education that demonstrate best practice necessitate an intensive and long-term commitment by both families and service providers and, in the best possible situation, should be sustained by way of collaboration with the client’s primary care physician (Sherman, et al., 2009). There are many reasons why veterans themselves decline opportunities to participate in psychoeducation, however, participation barriers should nonetheless be identified so as to inform the design process and improve program effectiveness. The implications for clinical programming should: (a) improve awareness of psycho-education and its advantages to mental health staff at a community-wide level; (b) provide pertinent and timely information to families about psycho-education as the need arises; (c) provide flexible programming to promote participation; (d) initiate networking opportunities with other families; (e) include efforts to normalise fears; (f) assess any possibility of domestic violence, suicidal ideation or child abuse within families; and (g) identify and provide support to veterans with unsupportive families (Sherman, Blevins, Kirchner, Ridener, & Jackson, 2008). 8. Best practices need concomitant data management solutions. In an era where the delivery of rehabilitation for people with mental illnesses has moved toward multidisciplinary case management models, clients have been reported as
specifying a preference for one continuing relationship with a clinician or team member (Crawford, et al., 2004). Clients’ preference for individualised case management has been emphasised in a service context where providers expect clients to repeat accounts of their previous problems and treatment to successive service staff. Data systems thus need to address the longitudinal nature of rehabilitation, the comprehensive nature of history taking, and reflect the integrated nature of the wider service system. Where veterans regularly receive treatment across multiple settings, the absence of a thoroughly devised method for the management and coordination of data has been associated with the incidence of medical error (Shay & Burris, 2008). Data management thus has implications for the best practice of psychosocial rehabilitation in maintaining the continuum of care and in delivering pertinent and timely services. A specialised data management approach would give close examination to: (a) the processes and systems employed for case reporting and record keeping over time; (b) the structure and recording of actions developed within multidisciplinary team meetings; (c) the protocols needed for effective case handover; and (d) the extent to which history taking across multiple contexts is assembled, organised and disseminated (Australian Centre for Posttraumatic Mental Health, 2009a). The design of data management systems for psychosocial rehabilitation need to work effectively in the context of longitudinal care arrangements but should also provide flexibility to ensure authentic record keeping and reliability over time, the latter of these being essential to the design of quality assurance and evaluation processes and the development of links for follow up. All data management systems should be framed by clear policy with respect to self-disclosure and confidentiality (Hebert, et al., 2008).
9. Best practices aim to deliver to the full spectrum of need. Psychosocial rehabilitation should aim to provide universal access, equity of access and parity across the spectrum of need. The model of care represented by psychosocial rehabilitation evolved to address the needs of people living with mental illnesses and has typically included components such as vocational rehabilitation, social functioning, case management, family support and psycho-education, accommodation support, and early intervention(Corrigan, Mueser, Bond, Drake, & Solomon, 2008). In ensuring parity across the spectrum of need, there are increased expectations on service providers to understand and work to ameliorate factors that may impinge upon individual access to pertinent services or to the effectiveness of programs. Factors that may bear upon access and efficacy within a multidisciplinary style mental health service include, to varying degree, aspects such as the individual’s physical mobility and wellbeing (Brown, DeLeon, Loftis, & Scherer, 2008; O'Sullivan, et al., 2006), cultural diversity (Tobin, 2000), other demographic determinants such as age-related factors (Drake, et al., 2003), geographical location (McCarthy, et al., 2009) and gender (Judd, Armstrong, & Kulkarni, 2009), the availability and suitability of housing or accommodation arrangements (Blackman, Anderson, & Pye, 2003; Browne, et al., 2008; O'Connell, et al., 2008) and the social environment, including peer supports (Hebert, et al., 2008), social networks (Harding, et al., 2008) and family cohesion (Bowling & Sherman, 2008). Added to these, policies governing the selection and exclusion of recipients for veteran entitlements have also been found to create barriers to access and parity, especially where co-morbidity is present (Frueh, Grubaugh, Elhai, & Buckley, 2007). While it is not possible to comment here specifically on all of the factors mentioned above, specific comment will be made of the role that support services to veterans’ families play in the delivering to the full spectrum of need. This is especially pertinent given that
family health and wellbeing has been singled out as a particularly important issue needing attention in the reform of mental health services to current and former defence force members in the Australian context (Dunt, 2009). The psychosocial needs of veterans cannot be addressed within a vacuum. The ICF framework (World Health Organisation, 2002b) identified personal and environmental factors as contributing to wellbeing, but families are an especially unique environmental support to the extent that they are an inter-subjective context. Couples and families have an effect on veterans recovering from an acquired disability and correspondingly, family members are affected at a number of levels by the challenges imposed by the new circumstances that disabling conditions bring to family life. There are challenges readjusting to civilian life and to the changes in circumstances that inevitably arise after periods away from family and friends. This context has been identified in the recommendations made in the review of mental health care in the ADF (Dunt, 2009). The recommendation most pertinent to parity concerns in psychosocial rehabilitation identified that mental health support plays an important role in the delivery of both primary care and mental health where family issues are involved. The report emphasised that mental health support should be part of any proposed multidisciplinary service approach and that services made available to families should provide components that support the members themselves especially where family issues are involved; thus bringing into focus a redefinition of “defence family” in order to improve the delivery of best practice (Dunt, 2009). Beyond the Australian context, research with veteran populations has suggested that there are both risk and protective factors involved in a family’s capacity to adapt to the new circumstances produced by the health or mental health of a family member (Bowling & Sherman, 2008). Protective factors include greater flexibility in the division of labour within
the domestic sphere, the use of active coping strategies to manage strong emotions, and the use of community and social supports to promote family cohesion. Risk factors for family distress included lack of support, younger or new families, and families with other stressors (Bowling & Sherman, 2008). It is important to facilitate veterans’ return to community life and facilitate their reintegration with family and a civilian work life. Seven strategies that support this transition include screening for mental and physical health conditions, peer support initiatives and webbased networking, national strategies to guide research and evaluation in order to identify specific needs, and national initiatives to guide the structure and dissemination of family support services (Mandersheid, 2007). 10. Best practices have built-in service evaluation systems. Service evaluation is central to best practices in psychosocial rehabilitation. The Australian national practice standards for the mental health workforce identified service evaluation as an essential mediator in the delivery of effective services to consumers across their lifespan (Commonwealth Department of Health and Ageing, 2002). The evaluation of psychosocial rehabilitation services can be cross-sectional and thus provide a representation of the effectiveness of processes, impacts or outcomes. Crosssectional analyses may magnify information in a range of domains such as clinical practices, service systems or the treatment models applied, but should be balanced by further information from consumers, their family/support persons, treatment teams, rehabilitation teams, program staff or program management (Anthony, 2001; Australian Centre for Posttraumatic Mental Health, 2009a; Meehan, 2007). Data can also be extracted across the continuum of care on the pertinence of initial assessments, on current performance or follow up. Finally, evaluation data should be available to enhance the capacity to establish whether
services are meeting existing levels of need, whether there are any unmet needs within the existing consumer population and if there is unmet need within the wider veteran community (Australian Centre for Posttraumatic Mental Health, 2009a, 2009b). The military and veteran literature makes little comment on service evaluation, although it has been noted that performance indicators are essential across the service system and at points like entry/access and assessment, and should include data on service user satisfaction to ensure that resources are targeted in a timely and relevant fashion. Evaluation data are best measured at regular intervals across the first year of rehabilitation to ensure that variations in the uptake and delivery of services can be monitored with greater focus (Zilke, et al., 2006). Towards the effective implementation of psychosocial rehabilitation to veteran clients The ten priorities presented here have summarised the essential elements needed to design a psychosocial rehabilitation system for veterans that reflects standards of best practice. Some priorities provide greater support to the concrete needs of the individual while others are systemic supports and only likely to be noticed by the rehabilitation client if absent or poorly designed. For example, vocational rehabilitation and effective case management are likely to be more highly valued by an individual client than data management, although they are all highly interdependent. Challenges facing the delivery of best practices Australia-wide nevertheless require innovative solutions at the level of policy and implementation. For example, telecommunications can play an essential role in addressing some of the challenges for implementation, especially those resulting from health workforce shortages and geographical distance. Telecommunications can support the professional needs of service providers around education and professional development, enable access to relevant supervision and make
available resources and essential tools needed in the management of data and case coordination. Telecommunications also have some role to play in the delivery of services, but would be best implemented as a support to conventional models of care rather than replace them (Australian Centre for Posttraumatic Mental Health, 2009a, 2009b). Best practices in psychosocial rehabilitation also need to account for the way that the symptoms of mental illness may interfere with the way clients choose to enter the system. Overcoming the personal factors that affect access, treatment seeking and service utilisation by people with complex needs require close attention. For example, the personal and cognitive consequences of having a mental illness may considerably challenge the way individuals perceive their right to access (Drapalski, et al., 2008). Further, the social stigma attached to mental illness can have a pervasive influence on the capacity of the individual to accept the need for help and to communicate that need (Dunt, 2009; Stecker, et al., 2007). This is particularly pertinent to the establishment of a satisfying work life and community tenure by people with mental health needs (Mental Health Council of Australia, 2007). The successful implementation of vocational services to people with complex needs would also benefit greatly from a conceptual reframing of the meaning of ideas like ‘vocation’, ‘work’ and ‘employment’(Mental Health Council of Australia, 2007). These ideas have often been used interchangeably in the delivery of vocational services, but they are not mutually inclusive in the context of an ongoing mental illness and certainly not in the context of the transition by former serving members of the defence forces to civilian life. Finally, quality improvements in the psychosocial rehabilitation provided to Australian veterans would be supported by evaluation processes and data collation mechanisms that permit the comparison of outcomes amongst clients with similar needs across different contexts. The attainment of goals and satisfaction with services perceived by clients become essential benchmarks for this kind of evaluation, but additionally they provide
indicators for the detection of unmet need; an important part of any evaluation process. Future research could thereby support best practices by refining systems for the collection and evaluation of client review data and in the comparison of need across different geographical and social contexts in which psychosocial rehabilitation is delivered in Australia.
Endnotes i
1) Social inclusion; 2) Prevention and early intervention; 3) Service access co-ordination and continuity of care;
4) Quality improvement and innovation; and 5) Accountability – measuring and reporting progress.
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Acknowledgements This paper has been produced with support of funding from the Australian Department of Veterans Affairs.
Table 1 Strategy used for a review of best practices in psychosocial rehabilitation Key words
Search terms
Sources used
Veterans Mental health Psychosocial rehabilitation Early intervention Family services Community integration Case management Parity in mental health service delivery Chronic conditions and mental health services Service evaluation
Veterans and military Mental health, mental illness or mental health services Psychosocial rehabilitation, psychiatric rehabilitation, vocational rehabilitation, supported employment, diversified placement, transitional employment peer support or clubhouse Early intervention, early detection or screening Psycho-education or family support services Community integration, recovery, social functioning, social rehabilitation, accommodation, housing, or residential support Case management, illness management, assertive community treatment or crisis intervention Ageing populations, women, social inequality or disadvantage Chronic illness, healthy lifestyle or return to work Service evaluation or quality assurance
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