Community Ment Health J (2012) 48:568–573 DOI 10.1007/s10597-011-9478-6
BRIEF REPORT
Needs Assessment of Individuals with Serious Mental Illness: Can It Help in Promoting Recovery? Shirli Werner
Received: 16 May 2011 / Accepted: 29 November 2011 / Published online: 4 December 2011 Ó Springer Science+Business Media, LLC 2011
Abstract Needs of individuals with serious mental illness (SMI) must be understood in order to promote recovery. This study examined the needs of 206 individuals with SMI and compared their perceptions with those of their professional caregivers. Needs were reported in the areas of accommodations, psychotic symptoms, daytime activity, intimate relationships, and psychological distress. Caregivers reported more met needs, while individuals themselves reported more unmet needs. Results suggest that in order to promote recovery, services for persons with SMI should be developed in accordance with patients’ most prominent needs, specifically in the social and personal areas of intimate and sexual relationships. Keywords Camberwell assessment of needs Needs assessment Serious mental illness Services
Introduction Recovery, according to the most widely used definition is ‘‘a deeply personal, unique process of changing one’s attitudes, values, feelings, goals, skills, and/or roles. It is a way of living a satisfying, hopeful, and contributing life even within the limitations caused by illness. Recovery involves the development of new meaning and purpose in one’s life as one grows beyond the catastrophic effects of mental illness’’ (Anthony 1993). One implication of this definition is that recovery is an individual process. Thus, mental health services aimed at promoting recovery can not S. Werner (&) Paul Baerwald School of Social Work and Social Welfare, Hebrew University of Jerusalem, 91905 Mount Scopus, Israel e-mail:
[email protected]
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be based on a single recovery model (Slade 2010). Needs assessment can form the basis of mental health (MH) resource allocation (Lasalvia et al. 2000) and treatment programs tailored to individual patient needs (Phelan et al. 1995) and the promotion of recovery. Needs have been defined as ‘‘the requirements of individuals to enable them to achieve, maintain or restore an acceptable level of social independence or quality of life’’ (Department of Health Social Services Inspectorate 1991). Understanding the needs of persons with serious mental illness (SMI) is critical, given the disadvantages they often face in social and personal areas of life beyond the disease itself (de Weert-van Oene et al. 2009). Studies conducted in the field of SMI have identified needs related to psychotic symptoms, physical disorders, psychological distress, occupational skills, and financial management (Kulhara et al. 2010; Slade et al. 1999), as well as social needs, including intimate relations and sexual expression (Wiersma et al. 1998). The first aim of this study was to examine the needs of individuals who receive services under the Israeli Rehabilitation of Psychiatrically Disabled Persons in the Community Act (2000). According to this unique law, all individuals with SMI have the right to receive rehabilitation services. Since the passage of this legislation in 2000, Israel has seen a rapid development in psychiatric rehabilitation services, mainly in the areas of housing, work, education, professional development, community and leisure activities (Shteruch et al. 2009). Because service development is an ongoing process, it is appropriate to assess the needs of service users after a decade since legislation of the law. An additional area addressed by the literature in relation to needs assessment, which might impact also recovery, is that of the differences in perceptions of needs between patients and service providers (Junghan et al. 2007;
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Macpherson et al. 2003). The importance of this question stems from the assumption that needs are a socially negotiated concept (Hansson et al. 2003) and that in order to satisfy them, it is important to take into account several perspectives (Macpherson et al. 2008). However, the findings of studies in this area are inconclusive, with some indicating relatively low agreement between patients and clinicians (Wiersma et al. 2009), while others show higher agreement, especially in domains with a relatively defined service response (e.g., housing) versus those without (e.g., intimate relationships; Grinshpoon et al. 2008; Lasalvia et al. 2000). Thus, the second aim of this study was to compare patients’ perceptions of needs with those of their professional caregivers.
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in 22 life domains using a 4-point scale: 0 = no need; 1 = met need—no need or moderate problem because of help provided; 2 = unmet need—current or serious problem; and 3 = don’t want to answer this question. The CAN has been reported to have face, consensual, and content validity, good inter-rater and test–retest reliability (Phelan et al. 1995). Demographic information included gender, year of birth, current living accommodations, and current day program. Disease-related information included age at first emotional difficulties, age at first hospitalization, and global assessment of functioning [GAF; (American Psychiatric Association 1994)]. GAF is a single-item measure of functioning, ranging from 0 (extremely severe dysfunction) to 100 (extremely good function).
Methods Procedure Participants A convenience sample of individuals with SMI, mainly schizophrenia, was recruited from various rehabilitation settings throughout Israel. The sample included 119 men and 87 women with a mean age of 43.2 (SD = 10.9). Of the participants, 92 resided in hostels, 79 in supported housing and 34 in hospitals. Most participants (n = 145) worked in supported employment; others worked either in open day settings or had no day setting. Additionally, professional caregivers for 112 of the patients also participated in the study. Although an effort was made to collect data from all professional caregivers, several of the community professionals that were approached did not consent to participate in the study. Additionally, no consent was provided for professional caregivers working in hospital settings (n = 34). Despite this limitation, there were no statistically significant differences in the age (t(204) = 1.55, P [ .05), number of years since first hospitalization (t(182) = 0.59, P [ .05), and current day program (v2(2) = 1.46, P [ .05) between individuals for whom a professional assessment was available and those for whom it was not available. However, more staff ratings were completed for female participants (v2(1) = 4.75, P \ .05). For the most part, the professional caregivers were the patients’ social workers, the managers at their living residence, or the ‘‘house mothers’’. Instruments Assessment of needs. This instrument was based on the Hebrew version of the Camberwell Assessment of Needs Short Appraisal Schedule, Patient version [CANSAS-P; (Trauer et al. 2008)]. The CANSAS-P is an adaptation of the CAN, which is the most widely used instrument for the assessment of needs in people with SMI. It assesses needs
The interviewers were given 1 month of training on the theoretical, practical, and research aspects of needs assessment, followed by 1 month of training on the use of the CANSAS-P, as well as ongoing training throughout the interview period. Interviewers introduced the study, its aims and procedures to staff members and service recipients and requested their agreement to participate in the study. Only those participants who provided their signed consent, were fluent in Hebrew, and were not in an active psychotic state were interviewed. The consent rate was 76%. Professional caregivers were also asked to provide a rating on the needs of the service user, based on their familiarity with the participant. Ethical Considerations The study was approved by the Hebrew University’s ethical committee and the Psychiatric Rehabilitation Unit within the Ministry of Health. There are no known conflicts of interest in this research. Further, the author certifies responsibility for this study. Data Analyses The percentages of patients with no need, met need, unmet need, and total number of needs for each of the 22 need domains were calculated. The mean number of met and unmet needs were calculated as suggested in the literature (Kulhara et al. 2010; Wiersma et al. 2009). The relationship between needs and background and disease-related characteristics were examined using Pearson correlations for interval variables and independent t-tests and one-way ANOVAs for categorical variables. Current living accommodations was coded as a three-category variable according
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to the amount of support provided: hospital, hostel, and supported housing. Current daytime program was also coded into three categories: no daytime activity, supported daytime activity (sheltered work and employment club), and open daytime settings (supported work and open market). Agreement between the patients’ and the professional caregivers’ ratings on individual need items was calculated by means of the Cohen Kappa (Cohen 1960), which adjusts for chance. Cohen Kappa was not calculated for the areas in which more than 90% of both patients and professional caregivers agreed that the individual had no needs (i.e., safety to others, alcohol and drugs). Kappa values above 0.4 were considered as moderate to substantial agreement; values between 0.2 and 0.4 were considered as fair agreement; and values between 0 and 0.2 were considered as slight agreement (Landis and Koch 1977).
Results Needs and Their Correlates Overall, patients reported a mean of 13.86 (SD = 3.45) areas with no needs; 5.34 (SD = 2.83) areas of met needs; and 2.55 (SD = 2.29) areas of unmet needs. The areas with the highest percentage of unmet needs reported were intimate relationships (35.9%), sexual expression (31.6%), and company (24.8%). Areas with the highest percentage of total needs (both met and unmet) were accommodations (82.1%), psychotic symptoms (52.4%), daytime activity (58.2), intimate relationships (55.8%), and psychological distress (55.3%). Age was found to be negatively associated with patients’ reported unmet needs (r(204) = .15, P \ .05). Regarding the association with gender, men reported a higher number of unmet needs (M = 2.84, SD = 2.27) than women (M = 2.16, SD = 2.27) (t(204) = 2.12, P \ .05). In terms of daytime activity, more unmet needs were found among individuals who had no daytime activity than among those who were in a sheltered or open work environment (v2(4) = 13.32, P \ .01). A higher percentage of unmet needs in the area of psychotic symptoms was also found among individuals without any daytime activity (v2(4) = 14.18, P \ .05). The highest percentage of met needs in the area of safety to self was found among individuals in open work settings (v2(4) = 14.81, P \ .05). As for association with type of residence, individuals living in hostels had the most unmet needs in the domain of information on condition and treatment, and hospitalized individuals had the least unmet needs (v2(4) = 13.16, P \ .05). Furthermore a higher percentage of unmet needs in the area of money was found among individuals living in supportive housing (v2(4) = 16.70, P \ .01). Finally, a
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higher percentage of unmet needs in the area of benefits was found among hospitalized individuals (v2(4) = 16.80, P \ .01). In regard to disease-related information, neither age at first emotional difficulties nor age at first hospitalization were found to be associated with any of the needs variables. Further, the GAF scores were found to be negatively associated with the total number of needs (r(185) = -.16, P \ .05) and positively associated with no needs (r(185) = .16, P \ .05). Agreement Between Patients and Professional Caregivers Independent t-tests revealed a higher mean number of areas of no need reported by the patients overall (M = 13.4; SD = 3.42) than by the professional caregivers (M = 12.2; SD = 3.07, t(111) = 3.60, P \ .001). Caregivers rated a higher number of met needs (M = 7.06; SD = 2.71) as compared to the patients (M = 5.80; SD = 2.47, t(111) = 5.06, P \ .001), whereas patients rated a higher number of unmet needs (M = 2.63; SD = 2.40) as compared to caregivers (M = 2.14; SD = 2.27, t(111) = 2.10, P \ .05). The strongest agreement between the patients and the professionals was found in the areas of safety to self (Cohen Kappa = 0.60), child care (Cohen Kappa = 0.58), sexual expression (Cohen Kappa = 0.55), and intimate relationships (Cohen Kappa = 0.51), while the lowest agreement was found in the areas of physical health (Cohen Kappa = 0.15) and use of the telephone (Cohen Kappa = 0.20).
Discussion The main aims of the current study were to assess the needs of individuals with SMI in Israel and to compare their perceptions with those of their professional caregivers. The results showed that more met needs were found in areas of basic needs, such as accommodations, food, daytime activities, and psychotic symptoms, than in areas of social needs, such as sexual expression. This finding is relatively unsurprising, given that the services outlined in the Israeli Rehabilitation Act (2000) refer mainly to housing and daytime activities, and also given that these services are easier to allocate than social needs. Similar to other studies (Eklund and Ostman 2010), we found that the areas of needs reported as unmet were mainly those which are more personal and subjective, including the need for company, intimate relationships, and sexual expression. Several explanations might be provided for this finding. First, it must be acknowledged that in Israel, as well as in other countries, fewer services are available in these areas, making such needs harder to fulfill. Second, even in
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cases where services are available, individuals may not know how to effectively use them. For example, the individual may join a club, but not know how to develop a meaningful relationship with another member. Indeed, previous studies have acknowledged that in some areas, it is a challenge to find effective treatment (Drukker et al. 2008). Finally, it is easier to develop and provide services in areas of basic needs than in areas of social needs. It is also possible that clinicians may feel uncomfortable asking clients about their needs or offering services in areas related to intimate and sexual relationships. Indeed, it has been found that MH providers rarely explore sexual issues with their patients (Quinn and Browne 2009) and fail to provide adequate support in this area (Stevenson 2004). Nevertheless, professionals must also attend to the social needs of patients in their care and recovery (Eklund and Ostman 2010). Regarding the comparison between the reports of patients and professionals, we found that care providers reported a higher number of met needs, whereas patients reported more unmet needs and more areas in which there were no perceived needs. These results suggest that the distinction between no needs and met needs is difficult to make and influences the agreement between patient and caregiver. If an area is relatively unproblematic to an individual, then most patients will infer that there are no difficulties in that area. However, care providers are more likely to conclude that the lack of perceived need is the result of services provided. This finding is in line with those of previous studies showing that patients are sometimes provided with services because of their availability rather than because of an actual need for care (McCrone et al. 2001). This may lead to an undesired situation in which individuals are fitted into available services rather than fitting the services to individual needs—a situation that would clearly require remediation within the rehabilitation system. Finally, although personal characteristics influence individual patient needs, it is known that needs may also differ according to cultural context and service provision in different countries. In comparing the occurrence of specific needs between the current sample and samples from other populations, both similarities and differences can be found. For example, the level of met needs in the current sample is higher than in a previous study conducted in Israel among 52 hospital inpatients (Grinshpoon et al. 2008). The level of met needs is also higher than that found in Australia among 108 community-dwelling individuals with SMI (Trauer et al. 2008) and in India among 100 outpatients with schizophrenia (Kulhara et al. 2010). Trauer et al.’s (2008) study was the first and, to the best of our knowledge, the only study to utilize the CANSAS-P version. The higher level of met needs in the current sample is seen
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mainly in the areas of accommodations, food, looking after the home, daytime activities, and physical health. As for unmet needs, the current sample was very similar to the Australian community sample, except in intimate relationships and sexual expression, in which the current sample had higher unmet needs. Although the proportion of unmet needs in the Indian sample was much higher on most domains than in the current sample, similar areas of needs were found to be unmet, specifically those of intimate relationships, sexual expression, company, psychological distress, daytime activity, psychotic symptoms, and information on treatment. These findings should be interpreted cautiously because the sample differed in terms of size and cultural background and the data were collected during different years. Given the comparison of the current results with previous studies, we may cautiously conclude that psychiatric rehabilitation services in Israel have been improving in many areas. The difference between the two inpatient samples might be attributed to recent changes in the hospital system. However, it should be noted that half of the individuals in the current inpatient sample took part in a group that aims to serve as a bridge between the hospital and the community. It is possible that this type of program helps to meet some of the individuals’ needs. It is interesting to point out that the two areas in which unmet needs were found to be higher in the current community sample are those of intimate relationships and sexual expression. It can be hypothesized that nowadays individuals with SMI feel that it is more legitimate for them to express such personal needs. Although it is more difficult to fulfill needs in these areas and effective interventions are currently lacking, services should turn their attention to meeting these more personal and social types of needs. The current study has several limitations. First, the sample is a non-probability sample. However, it should be noted that participants were recruited from a large number of different services across the country. Second, participants were interviewed by several interviewers, though this practice is common in studies conducting needs assessments (Trauer et al. 2008; Wiersma et al. 2009). Ongoing training was provided in order to increase inter-rater reliability. Third, professional caregivers were only available for part of the sample.
Conclusions and Implications for Policy Makers and Service Development Findings from this study are informative for policy makers in service planning and development. Budgets should be allocated to the development of services which are in accordance with patients’ most prominent needs,
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specifically in the social and personal areas of intimate and sexual relationships. Further, policy makers should considering updating the services outlined in the Israeli Rehabilitation Act to be more inclusive of services within the social realm. Additionally, in an effort to promote recovery and assure quality, services should be tailored to each setting and to each individual. Care systems ought to avoid providing services for which there is no need (Yeh et al. 2011) and the needs assessment of persons with SMI should be a continuous process, rather than a one-time event, in order to adjust the services provided to the changing needs of the patient population. In this way services may tailor themselves to promote recovery while providing a person-centered approach. Mental health services can facilitate the life recovery of the individual by helping people make the most of their abilities and live satisfying purposeful and valued lives (Perkins and Repper 2004). In order to attain a satisfactory recovery process, we recommend that the CAN be made an integral part of the service provision process for individuals with SMI (Drukker et al. 2008) and that both staff and patient perspectives be considered when developing services to meet patient needs (Junghan et al. 2007). In terms of future research, we recommend adding qualitative interviews to needs assessments in order to collect important information on those areas in which individuals with SMI feel the need for additional services. Acknowledgments The authors would like to acknowledge the interviewers that took part in this study and all the individuals who agreed to participate in the study.
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