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

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. Matthews

2 and Virginia J. Lewis

1,3

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 evidence-

based 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) re-

entry (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 evidence-

based 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 psycho-

education, 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 web-

based 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. Cross-

sectional 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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