Core characteristics of included trials and studies are outlined in **Table 1** and are briefly described below. Sixteen of the 21 clinical trials resulted in one study/publication, four trials were published as two publications (40, 41, 51, 56–59, 65) and (55, 56) and one trial was reported in six studies/publications (42– 47). Case management was most frequently compared with existing referral procedures (11 trials). Other trials compared case management with existing treatment (4 trials), parole supervision

(n = 2), standard probation (n = 2), routine outreach (n = 1), or passive referral (n = 1).

A total of 7,431 unduplicated participants were randomized in the 21 clinical trials. The mean size of the trials was 354 subjects, ranging from a small study with 41 subjects (38) to a large trial including 1,369 subjects (7). Two typologies of substance use problems could be discerned: heroin or cocaine users involved in injectable drug use (IDU) (6 trials) and polysubstance abusers, that is, a mixed group of substance abusers where no one type of drug predominated (10 trials). Two trials contained a relatively homogenous substance abusing population consisting of individuals who were alcohol dependent (39, 64). Typically, study authors reported findings on specific subpopulations, including individuals who were homeless, dually diagnosed, HIV positive or female only (with children). Some of the study populations consisted of substance abusers involved in the criminal justice system: individuals on probation (7, 60) or persons on parole (36, 61). The Morgenstern trials (12, 55) involved substance users in public welfare settings, while two trials recruited individuals in central intake units (48, 57). At the time they entered the study, the majority of study participants were not in treatment. Only three clinical trials were composed exclusively of in-treatment substance abusers (38, 40, 42) (see **Table 1**).

Several case management models have been identified in the literature [see (18)]. The term "generalist case management" was assigned to four clinical trials that did not specify a conceptual or working name for the model of case management that was used. The term "intensive case management" was retained for the four trials using the term, although none specified what the term "intensive" meant. Six trials described case management as "strengths-based," three as "Assertive Community Treatment" (ACT) and four were labeled as "other", as they referred to case management using an unusual term: hybrid case management (49), outreach case management (38), coordinated care management (12, 59) or probation case management (60). Ten of the selected trials reported using both supervision and a manual/protocol to monitor quality control and fidelity of the case management intervention. Three trials used a manual, but not supervision, and conversely, three trials used supervision, but not a manual. Five trials used neither a manual nor supervision.

Out of the 7,431 unduplicated participants randomized in the 21 clinical trials, 6,179 were re-contacted at the first followup point, which means an overall follow-up rate of 83.2%. First follow-up moments for clinical trials ranged from 1.5 to 12 months for one of the studies. The modal first follow-up assessment was 6 months. Among the 21 clinical trials, seven had follow-up rates of 100% because information came from administrative records. Five trials had follow-up rates of 90.0– 99.9%, 3 trials had rates between 80.0 and 89.9% and 5 trials had rates between 70.0 and 79.9%. One trial had unsatisfactory follow-up rates below 50%. Sample and follow-up rates were not used when follow-up data consisted of participants who had provided data at only one of multiple follow-up points. In some instances, it was not possible to identify exact sample sizes at each follow-up measurement due to unclear information provided in the retrieved publications.

#### Synthesized Findings

All 21 clinical trials (31 studies in total) that reported a comparison of case management (CM) and TAU on one or more outcome indicators were included in the initial metaanalysis. The overall effect size for case management compared to TAU across all outcome categories and moments was small and positive, but statistically significant (z = 3.34, p < 0.001) with a mean effect of SMD = 0.179 (95% CI [0.07–0.28] (see **Figure 2**). Observed effect sizes were positive for 16 of the 21 studies, with five exceptions (12, 36, 49, 63, 64). Overall effect size estimates for the clinical trials ranged from −0.202 (64) to 1.707 (38).

There was little evidence for publication bias, as a visual examination of a funnel plot of standard errors appeared relatively symmetric (see **Figure 3**). Based on the trim-andfill method, one effect size was added, and so the estimated overall treatment effect changed slightly (from 0.179 to 0.170). Egger's intercept test confirmed that there was little evidence for publication bias (t = 1.38, df = 19, p = 0.18).

We found some evidence for heterogeneity between studies. The estimate of the systematic between-study variance is equal to 0.018, I² is equal to 35.59. This means that about 36% of the variance in observed effect sizes does not seem due to random sampling variance, but rather to systematic variation between studies. Despite this relatively large proportion of variance, the Q-test showed that this variance is statistically not significant when using a significance level of 0.05 (Q = 31.05, df = 20, p = 0.06). This does, however, not exclude the possibility that there are moderator variables affecting case management outcomes. Therefore, we performed several moderator analyses.

The effect of case management was studied using 10 different outcome types that were categorized into two broad groups: (1) treatment tasks (linkage with substance abuse and ancillary services, retention in substance abuse and ancillary services, and attitudes toward treatment) and (2) personal functioning outcomes (substance use, health status, legal involvement, risk behavior, and social functioning) (25). Of the 21 trials, 19 contained treatment task outcomes, and 15 trials reported personal functioning outcomes. Two separate meta-analyses were performed for these two categories of outcomes.

#### Case Management and Treatment Tasks

For treatment tasks, a positive effect size was found in 17 (out of 19) trials ranging from 0.037 (39) to 1.707 (38) (see **Figure 4**). Only two trials showed a (very small) negative effect size for treatment tasks (49, 63). Seven of the trials had effect sizes above 0.5, what can be considered as a moderate effect (66). Overall, a weak to moderate effect of CM was found regarding treatmentrelated tasks, SMD = 0.33, 95% CI [0.18, 0.48]. Again, no clear evidence for publication bias was found.

Based on separate meta-analyses, we estimated the effect sizes for each of the five treatment tasks. The largest effect size was found for retention in substance abuse treatment (SMD = 0.47, 95% CI [0.13, 0.81]). Smaller effect sizes were found for linkage with substance abuse services (SMD = 0.23, 95% CI [0.11, 0.35]), satisfaction with treatment

(SMD = 0.17, 95% CI [−0.04, 0.38]), retention in nonsubstance abuse services (SMD=0.12, 95% CI [−0.01, 0.25]) and linkage with other types of services (SMD = 0.11, 95% CI [−0.11, 0.34]).

#### Case Management and Personal Functioning

Of the 15 clinical trials with personal functioning outcomes, all but four had positive effect sizes that ranged from 0.003 (53) to 0.608 (62) (see **Figure 5**). Three studies had a very small negative effect size for functioning outcomes (12, 36, 49), but one study reported a negative effect size of −0.34 (64). Effect sizes were in general very small, including only three trials (39, 52, 55) with an effect size >0.20 (66) and two other studies (39, 60) with an effect size around 0.20. The overall SMD for personal functioning outcomes (SMD = 0.06, 95% CI [−0.02, 0.15]) was very small and statistically not significant. A funnel plot does not give evidence for publication bias.

Based on separate meta-analyses, we calculated the effect sizes for the five personal functioning outcomes. The biggest, although small and non-significant effects were found for social functioning (e.g., housing, employment) (SMD = 0.14, 95% CI [−0.01, 0.28]) and substance use outcomes (SMD = 0.10, 95% CI [−0.02, 0.21]). Even smaller (positive) effects favoring case management were found for risk behavior (SMD = 0.05, 95% CI [−0.07, 0.17]) and legal involvement (SMD = 0.02, 95% CI [−0.07, 0.10]), while a similarly small negative effect was found regarding health outcomes (SMD = −0.16, 95% CI [−0.40, 0.08]). None of these effects, however, were statistically different from zero.

#### Moderators

Six moderator variables were tested for their impact on the efficacy of case management, i.e., model, treatment status, setting, population, and intervention quality (manual or supervision).

Studies were characterized by the type of case management model they used. The highest effect sizes were found for generalist CM (k = 4): SMD=0.32, 95% CI [−0.05, 0.68], the lowest for Assertive Community Treatment (k = 3): SMD = 0.01, 95% CI [−0.25, 0.27] (see **Figure 6**). Estimated effect sizes were very similar for strengths-based CM (k = 6): SMD = 0.22, 95% CI [0.05, 0.38], intensive case management (k = 4): SMD = 0.22, 95%CI [0.06, 0.38], and for other types of CM (k = 4): SMD = 0.20, CI = [−0.33, 0.72]). Differences between CM models in the size of the intervention effect were statistically not significant (Q = 2.57, df = 4, p = 0.63).

Included studies were categorized as having participants who could be either "in" or "out" of treatment when the intervention started. Because the treatment status could vary within studies, we performed two separate meta-analyses. If the treatment status was 'in', the estimated mean effect was 0.18 (k = 3). If the treatment status was "out," the overall effect size was very similar (SMD = 0.17, k = 19).

Studies were characterized as having participants in one of four types of settings at the time the study started: community/street (SMD = 0.16), criminal justice system (SMD = 0.20), substance abuse treatment (residential, outpatient, or mixed) (SMD = 0.23), or welfare offices (SMD = 0.19). Differences between these four categories appeared to be very small and statistically not significant (Q = 0.24, df = 3, p = 0.97).

Studies were characterized by the primary type of substance use, either alcohol, poly substance use or IDU. Although the estimated effect size for studies targeting injectable drug users was considerably higher (SMD = 0.33 for IDUs vs. 0.18 for poly substance users, and 0.03 for alcohol abusers), the moderating effect of the type of population on CM outcomes was statistically not significant (Q = 1.29, df = 2, p = 0.52).

Clinical trials were identified as having methods in place to promote the fidelity with which the intervention was implemented, one of these being a manual/protocol and the other clinical supervision. No significant difference in estimated effect size was found between studies with (SMD = 0.20) and without supervision (SMD = 0.16) (Q = 0.10, df = 1, p = 0.75). Also, no significant difference was found between studies with (SMD = 0.17) and without manual (SMD = 0.19) that described the intervention in detail. Effect sizes were very similar (Q = 0.05, df = 1, p = 0.83).

#### Risk of Bias

We assessed all included studies (n = 31) for risk of bias, since several clinical trials included ≥1 publication/study that focused on specific outcomes or follow-up moments. We distinguished between following types of bias: selection bias, performance bias, attrition bias, detection bias and reporting bias [see (32)]. For each type of bias, studies were judged to be at "low," "high" or "unclear" risk of bias.

Eighteen studies (11 clinical trials) reported an adequate randomization method and were judged to be at low risk of bias

for "Random Sequence Generation," 10 studies (4 clinical trials) were at high risk of bias, while the risk was unclear in 3 studies. Four early studies (7, 36, 37, 42) did not apply a systematic method of sequence generation. Similarly, 18 studies (13 clinical trials) described adequate concealment of the allocation sequence and were at low risk of bias for "Allocation Concealment," 8 studies (4 clinical trials) did not report an adequate procedure for allocation concealment and in 5 studies this risk was deemed unclear. Due to the type of intervention, participants and staff could not be blinded for receiving/providing case management. Still, blinding of participants and personnel (performance bias) was assessed to be at low risk of bias in all studies (21 trials), as it was deemed unlikely that knowledge of receiving case management will have affected outcomes. Researchers reported blinding of outcome assessors in 20 studies (15 clinical trials), which were assessed to be at low risk of detection bias. The risk of detection bias was high in 6 studies (2 clinical trials), and in 5 studies the risk was unclear. Follow-up rates were high in most studies, because at least part of the outcome data were collected using administrative records. One trial had very low follow-up rates (<50%) and 15 trials had a high follow-up rate ≥80%. Attrition bias was judged as high risk in 11 studies (6 clinical trials), primarily due to follow-up rates <70% for at least some outcome areas. The risk of within-study selective outcome reporting was deemed low in most studies (n = 23; 17 trials), while high risk of reporting bias was observed in 7 studies (3 clinical trials) and "unclear" in 1 study.

#### DISCUSSION

#### Summary of Findings

The current study examined the effects of case management regarding various indicators of recovery and service utilization, updating results from two previous meta-analyses (2, 25) and adding effect sizes for various types of outcomes to available systematic reviews (14, 27–29). Outcomes were clustered around 5 personal functioning and 5 treatment-related outcomes as described elsewhere (25). The primary results from the earlier studies were supported: case management was significantly more effective than TAU conditions for improving outcomes, although the overall effect was small (SMD = 0.18). The effect size was significantly larger for treatment related tasks (SMD = 0.33) than for personal functioning outcomes (SMD = 0.06), questioning its additional value in individuals' recovery process. However, substantial heterogeneity was observed between as well as within studies.

The findings suggest a positive role for case management over standards of care, but two factors make it difficult to fully understand the findings. First, numerous diverse outcome indicators (>450) are presented in clinical trials, including reduced substance use and criminal involvement, improved parenting skills and overall well-being, and linkage with treatment. Such broad expectations of a single intervention seem unwarranted, "as it is unlikely that any single psychosocial intervention can affect so many different areas of participants' lives" [(25), p. 614). Second, the TAU comparisons varied widely in their intensity, providing very different comparisons to case management. In ten of the trials, the TAU comparison was "existing referral practices," a broad category that was usually ill-defined. In three trials, the comparison condition was either residential or aftercare treatment, both of which would quite possibly be more intensive than case management. Finally, in four trials TAU actually consisted of probation or parole, which is certainly an intensive comparison condition given the possibility of individuals being incarcerated. The finding that case management had a weak to small effect across all outcomes, even when some of the comparison conditions were relatively intense, suggests that the reported effect sizes are conservative and would have been larger if case management was compared to no treatment or waitlist controls (25).

### Differential Efficacy for Treatment Task and Personal Functioning Outcomes

Previous meta-analyses have suggested a differential effect of case management based on the type of outcomes being considered. One group of outcomes—treatment tasks—focused on the process of treatment, that is, do individuals link with and stay involved in both substance abuse treatment and ancillary substance abuse-related services. Attitudes toward attending treatment are also part of treatment task outcomes. The second group of outcomes consists of aspects of psychosocial and behavioral functioning that are generally the primary focus of substance abuse treatment. These areas encompass improved functioning regarding substance use, physical and psychological health, legal involvement, social status (housing, employment, family relations), and risk behavior. A clinically important and statistically significant difference was observed in case management's impact on treatment task outcomes compared to personal functioning outcomes [see also (2, 25)]. Effect sizes for the highest personal functioning areas, social functioning and substance use, were considerably lower compared with effect sizes for following treatment tasks: retention in substance abuse services and linkage with substance abuse and ancillary services.

Similar results were found in meta-analyses of case management with other mental health populations (21, 67, 68). Given the primary goals of case management (to help individuals identify needed services, facilitate linking with these services, monitor treatment participation and retention, coordinate service provision, and advocate on clients' behalf) (31, 69), its greater effect on treatment tasks is not surprising. The findings support an obvious premise: if individuals with SUDs do not link with and remain in treatment, especially in substance abuse services, they cannot benefit from these services (25). Consequently, case management should be regarded as a missing link in substance abuse treatment (24, 70).

### Case Management's Role in Supporting Recovery

The emerging international (mental health) recovery movement has stressed the importance of personal and subjective experiences of recovery [e.g., (71, 72)], besides "clinical recovery." The latter refers to the absence of symptoms and illness ((i.e. most personal functioning outcomes) (73, 74), while "personal recovery" refers to a deeply personal process of change and "living a satisfying, hopeful and contributing life, within the limitations imposed by illness" [(75), p. 15]. Addiction recovery has been defined in more behavioral terms and is characterized as involving control over substance use, global health and well-being, and active citizenship (or community participation) (76, 77). Only a few studies selected for this review have included measures of personal recovery like quality of life and overall daily functioning, despite the recognition of SUD as a chronic relapsing disorder (17). The effect of case management on personal functioning outcomes found in this meta-analysis was weak to small, and only for employment and housing outcomes (social functioning, SMD = 0.14) and substance use (SMD = 0.10) a weak effect was found. A weak, negative effect was found for health outcomes (SMD = −0.16), a combination of physical and mental health indicators, typically measured from a clinical recovery perspective. Recovery should be regarded as a long process involving several life domains and abstinence is not a necessary, nor a sufficient marker of recovery, as it concerns a personal and experiential journey to life satisfaction and well-being (72). The transition from early stages of recovery to 'stable recovery' averages around 5 years, with the recognition that there are multiple pathways to recovery (78).

All models of case management have in common the goal of linking persons with SUDs and their families with needed resources in order to promote personal functioning and recovery (57). Linking with and effective use of community resources and services addresses their needs for substance abuse treatment, safe housing, improved employment, management of health problems, and avoiding legal problems. Resolution of these problems should increase individuals' opportunities to effect recovery. Case management further promotes that persons with SUDs keep on using these services and stay in treatment (14, 28, 41). Consequently, case management is thought to directly affect treatment-related outcomes (e.g., linkage, retention) and, by doing so, to indirectly impact on personal functioning outcomes (e.g., alcohol and drug use, employment, health status, family relations) and thus recovery.

Although case management was not found to be directly associated with improved personal functioning, two other mechanisms may be in operation (14, 25, 56). First, case management may have an indirect effect on separate personal functioning outcomes and overall recovery through its impact on treatment tasks such as linking and retention. Treatment participation and retention are widely documented predictors of remission and recovery (73, 79). For example, recently released parolees with SUDs who were receiving case management, were retained in treatment significantly longer than persons not receiving this intervention (60). Longer retention was associated with reduced substance use, less criminal justice involvement and risk behavior, and improved housing and employment situations at follow-up. Consequently, improved functioning should be viewed as a result of case management's ability to improve linkage and retention rather than as a direct effect.

Second, personal functioning outcomes—and eventually recovery—may be enhanced by combining case management with specialized skills and activities (e.g., a strengths approach) (25). Case management may include a variety of direct interventions, ranging from providing information and advice and substance abuse counseling to being clients' primary therapist in clinical models of case management (18). For example, clinical case managers receive specialized training to combine therapeutic support and case management (80). In this instance, it may be warranted to expect that case management contributes to improved personal functioning outcomes such as reductions in psychiatric symptoms and improved well-being (25, 81). Case management can also be combined with other interventions such as risk reduction activities, motivational interviewing, and recovery management [see (51, 62)]. Expanded case management services have been frequently applied among substance users with additional mental health (82, 83) and HIV/AIDS problems (49, 84). It is a standard part of comprehensive case management models like intensive case management (53, 55) and Assertive Community Treatment (ACT) (54, 64). Importantly, various studies were excluded from this review, as they offered comprehensive interventions combining case management with other viable approaches (e.g., cognitive behavioral therapy, Housing First programs), in which case management effects could not be disentangled from these additional interventions. Such promising combinations are worthwhile reviewing, although separating specific case management effects will be challenging. These observations illustrate that the variety between case management conditions (from brief models to comprehensive, long-term approaches) may at least be as diverse as the variety observed in TAU conditions, which is likely to affect case management's efficacy.

### Toward a Recovery-Oriented Research Agenda

The increased interest in case management resulted in the addition of several new trials (especially from outside the US) in this updated meta-analysis and over 130 recent studies (nonrandomized, quasi-experimental, and observational studies) were excluded, primarily because they didn't apply a randomized study design or did not focus exclusively on substance users. Case management is often used to address severely disadvantaged populations with multiple and complex needs. This does not only challenge the randomization process in real-life settings and leads to the adoption of less rigid study methodologies (85), but also reduces the likelihood of finding large effect sizes (14). Also, the finding that case management is effective for improving linkage has contributed to its incorporation in comprehensive treatment programs (86–88) and to its acceptance as a mainstream intervention. In some clinical trials (89–91), case management was even applied as a standard of care control condition, assuming that this intervention would be inferior to the experimental intervention. These studies were not included in this systematic review, but should be reviewed in a separate meta-analysis that compares case management to other active interventions. Given the comparison with other viable (or even evidence-based) interventions, it is likely that case management's efficacy will be lower than compared with TAU.

Despite the increasing popularity of quality of life and other indicators of subjective well-being for evaluating interventions among persons with chronic disorders (92), such outcomes have hardly been studied in clinical trials of case management. Although these studies have often included self-report measures of health and substance use outcomes, they mostly refer to high expectations and socially desirable changes (e.g., abstinence from alcohol and drugs, no arrests, employment) rather than to individuals' perceived well-being and quality of life. Yet, such measures might shed an alternative light on individuals' situations and personal functioning outcomes (93). As case management is primarily applied among severely affected substance using populations, a focus on subjective and personcentered outcomes is more likely to demonstrate the benefits of case management in individuals' daily lives. Introducing a recovery perspective in controlled studies of case management will also allow to measure its impact on individuals' satisfaction with life and participation in society, as well as factors directly or indirectly affecting it. A number of trials were recently set up or are still ongoing that could potentially fill some of these gaps (94, 95).

### Quality of the Evidence and Limitations of This Review

According to the GRADE criteria (96), the quality of the evidence regarding the reported outcome categories would be rated moderate to low, primarily due to multiple risks of bias and substantial heterogeneity, or a combination of both. About 1 in 4 studies did not describe the randomization and concealment method adequately. Outcomes assessors were only blinded for group allocation in 2 out of 3 studies and most studies did not use blinding of study participants and case managers. When outcomes are self-reported behaviors and when participants are not blinded to study conditions, overestimation of intervention effects is a potential risk (97). However, since administrative data or objective outcome indicators (e.g., biological markers) were used in at least half of the trials, this risk was minimized. Attrition rates were not acceptable in one trial (42). Followup rates sometimes differed within one trial, as several studies used administrative records and assessments to evaluate study outcomes. Attrition bias may limit the applicability of study results or the power to detect between-group differences (97). Despite low attrition in some studies, this may not be problematic if attrition rates are similar in the experimental and control condition (97). We observed few indications for differential attrition rates in the included studies. Finally, publication bias may hamper the conclusions from any systematic review. Visual inspection of funnel plots suggested no evidence for publication bias, and the use of the trim-and-fill method only changed effect sizes slightly. Still, 1 in 5 studies were at high risk of reporting bias, as only some outcome indicators were reported in retrieved publications. Since this meta-analysis is based on published study outcomes, we may not underestimate the likelihood of publication bias as journals tend to publish studies including significant findings. Yet, the fact that several of the included RCTs generated no (or even inverse) effects favoring the case management condition illustrates that reported outcomes are not limited to significant positive outcomes.

This meta-analytic review has some limitations, most of which are typical for meta-analyses (98). First, all included studies were randomized clinical trials (25). Quasi-experimental trials are another source of evidence for case management studies, but these were excluded as we focused on studies in which all subjects were randomly assigned to either case management or a comparison condition. Second, even though all studies in this review were randomized, substantial methodological differences were observed (25). For example, studies used a variety of instruments to measure personal functioning outcomes, and at least 15 different substance use measures were used. This resulted in numerous different outcomes per outcome category. Third, fairly distinct populations were included in the clinical trials, e.g., persons with dual diagnosis, female welfare recipients, homeless alcohol dependent men, HIV infected intravenous drug users and incarcerated drug offenders. Even within these groups, study participants had diverse treatment needs, which may affect case managers' activities (14) Moreover, individuallevel characteristics determine the effects of an intervention. For instance, there is evidence that SUDs are associated with various individual characteristics such as gender, comorbid disorders and psychosocial functioning [e.g., (99)], and it is possible that the likelihood of success of case management is associated with such factors. Ideally, this meta-analysis should have been based on the raw data of all individuals included in the selected clinical trials, so that we could perform a multilevel analysis accounting for covariates at the within-study level, in addition to covariates at the between-study level. By modeling the interaction effect of these individual characteristics and the intervention, we could have evaluated the moderating effects of these characteristics. In this meta-analysis, however, we had to rely on effect sizes summarizing effects for whole samples of participants, since the raw data were not available. It would still be interesting to study moderating effects of individual characteristics aggregated at sample level, but unfortunately, individual participant characteristics were not systematically measured and reported in the selected studies, so that we were not able to perform such moderator analyses (with the exception of the type of population studied). Therefore, part of the between-study variance in treatment effects may be due to differences in the composition of the samples in terms of participant characteristics. Fourth, in the absence of fidelity measures, we could not determine case management dosage or quality, nor could we control for eventual differences through moderator analyses (25). Fifth, we could not quantify all of the intervention features that might affect outcomes, although we used several characteristics of case management as moderators to help explain its efficacy. Case management is often characterized as being contextual and reflective of the network of services in which it is implemented (23), suggesting that the availability of services influences its overall efficacy (25). Consequently, the quality of service provision is likely to be beyond the control of case managers, even when resources are available. Finally, all study outcomes are characterized by substantial heterogeneity between and within study outcomes, which can be explained by the large variation in study populations, settings and treatment status, but also by within study variation regarding population, case management dosage and multiple follow-up measurements. We tried to control for some of these influences through moderator analyses.

#### CONCLUSION

Three extensive meta-analyses, including this one, have now confirmed that substance abuse case management is efficacious in improving important treatment-related outcomes such as linking with and staying engaged (retention) in substance abuse and ancillary services compared with standards of care. Substance abuse programs often experience challenges in delivering and coordinating ongoing support and in providing access to additional services for persons with SUDs and multiple and complex problems. Enhanced linking and retention in substance abuse and ancillary services have been associated with improved abstinence rates (100), less frequent hospital readmissions (101), and adequate functioning in the community (102). Linking with and engaging in treatment are therefore necessary prerequisites to persons with SUD having an opportunity to benefit from these services. Although most models of case management seem to be equally effective in promoting these outcomes, this point is still not clear given the shortage of (comparative) trials of models of case management. Substance abuse case management did not have a significant direct effect on personal functioning outcomes compared with standards of care. The positive, but limited impact of this intervention on substance use and other clinical recoveryrelated outcomes is supposed to be mediated by case managed individuals' use of substance abuse and ancillary services and

### REFERENCES

participation in treatment. Consequently, case management should be an integral part of comprehensive, wrap-around interventions to promote linkage and treatment participation and retention, and indirectly, personal functioning outcomes and recovery.

Further areas of research are at least 3-fold. First, studies that continue to include personal functioning outcomes should use methodological strategies that allow to assess the relationship between treatment linkage and retention on the one hand, and improved functioning outcomes on the other hand. Second, additional research is needed regarding some outcome categories (e.g., retention in and satisfaction with treatment), as case management is most likely to favor this type of understudied outcomes. Some type of outcomes have hardly been assessed in case management studies (e.g., quality of life, subjective well-being), although such indicators of personal recovery may enhance our knowledge substantially. Also, intensity and dosage of case management have been poorly studied. Third, despite the evidence that case management works for some specific purposes and populations, it remains largely unknown how it works and for whom at various stages of the treatment continuum. Future reviews should consider including quasi-experimental studies, since such designs usually resemble real-life settings more closely and the eventual question whether something works is whether it works in practice rather than under strictly controlled study conditions.

### AUTHOR CONTRIBUTIONS

WVDP together with RCR selected the studies for this review, checked extracted data, assessed risk of bias in the selected studies, wrote the results and discussion section, and supervised this publication. RCR together with WVDP selected the studies for this review, extracted data from the selected studies and managed in- and excluded studies, assessed risk of bias in the selected studies and wrote the introduction, and methods section. JDM contributed to the search and study selection process and helped with writing the background and discussion section. WVDN calculated all effect sizes based on the extracted data, ran all meta-analyses, assessed various types of bias and revised the methods, and results section.

disorders: findings from the global burden of disease study 2010. Lancet. (2013) 382:1575–86. doi: 10.1016/S0140-6736(13)61611-6

**Conflict of Interest Statement:** RCR was involved in two of the RCTs included in this review (40, 57).

The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Copyright © 2019 Vanderplasschen, Rapp, De Maeyer and Van Den Noortgate. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

# Mobile Intervention for Individuals With Psychosis, Dual Disorders, and Their Common Comorbidities: A Literature Review

#### *Antoine Pennou1,2\*, Tania Lecomte1,2, Stéphane Potvin2 and Yasser Khazaal2,3*

*1 Schizophrenia and Psychoses Study Laboratory for Intervention and Recovery, Department of Psychology, University of Montreal, Montreal, QC, Canada, 2 Research Center of the Montreal Mental Health University Institute, Intervention Axis and Services & Neurobiology and Cognition, Mental Health University Institute of Montreal, Montreal, QC, Canada, 3 Addiction Medicine, Department of Psychiatry, Lausanne University Hospital, Lausanne, Switzerland*

#### *Edited by:*

*Carlos Roncero, University of Salamanca Health Care Complex, Spain*

#### *Reviewed by:*

*Giovanni Martinotti, Università degli Studi G. d'Annunzio Chieti e Pescara, Italy Miguel Ruiz-Veguilla, Virgen del Rocío University Hospital, Spain*

> *\*Correspondence: Antoine Pennou<EMAIL_ADDRESS>
#### *Specialty section:*

*This article was submitted to Addictive Disorders, a section of the journal Frontiers in Psychiatry*

*Received: 14 December 2018 Accepted: 17 April 2019 Published: 03 May 2019*

#### *Citation:*

*Pennou A, Lecomte T, Potvin S and Khazaal Y (2019) Mobile Intervention for Individuals With Psychosis, Dual Disorders, and Their Common Comorbidities: A Literature Review. Front. Psychiatry 10:302. doi: 10.3389/fpsyt.2019.00302*

Over 50% of people diagnosed with a severe mental illness, such as schizophrenia or bipolar disorder, will meet criteria for a substance use disorder in their lifetime. This dual disorder often starts during youth and leads to significant societal costs, including lower employability rates, more hospitalizations, and higher risk of homelessness and of suicide attempts when compared to those with a serious mental illness without substance misuse. Moreover, many individuals presenting with comorbid disorders also present with other psychological difficulties as well, such as personality disorders or anxiety and depression, also known as complex comorbid disorders. Transdiagnostic treatments that focus on core difficulties found in people with complex dual disorders, such as emotional regulation, are direly needed. Emotional regulation skills can help reduce distress related to psychotic symptoms and maintain abstinence in substance use disorders. New technologies in the field of communications have developed considerably over the past decade and have the potential to improve access to such treatments, a major problem in many health care settings. As such, this paper aims at: presenting core difficulties present in many individuals with dual disorders, reviewing the scientific literature pertaining to the use of mobile applications in mental health and addictions, and presenting the development and potential of a new application for emotional regulation for people with dual disorders.

Keywords: severe mental illness, dual disorders, schizophrenia, psychosis, substance use disorder, mental health apps, emotion regulation

### INTRODUCTION

Severe mental illness (SMI) typically includes psychotic episodes and can be characterized by the presence of positive (e.g., delusions, hallucinations) symptoms, but also negative or depressive symptoms (e.g., flat affects, avolition) or symptoms of disorganized thought and behavior (1). It is also in this category that bipolar disorders are grouped, which are characterized *inter alia* by the alternation between depressive and manic or hypomanic episodes (i.e., irritable or abnormally high mood). It is estimated that about 3.5% of the population will be diagnosed with an SMI at some point in their lives—the highest incidence reported or recorded being between 15 and 30 years (2). SMI is also characterized by mild to moderate cognitive deficits in the majority of individuals (25% of

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them will maintain a cognitive functioning within the norm) (2). Although they have traditionally received less attention than the symptoms associated with psychosis (e.g., positive symptoms), these features are among the most important determinants when it comes to estimating the patient's capacity to function autonomously in his/her environment (2, 3).

SMIs are marked by social functioning difficulties (more specifically difficulties starting or maintaining a conversation, attaining a goal, or meeting basic needs requiring a simple conversation/interaction with others). Furthermore, these difficulties will lead to social integration problems that can occur throughout different stages of the disorder (2). Studies report that the fear of being stigmatized and the fear of being judged (the latter often linked to social phobia) are two of the most frequently reported obstacles to integration by participants (4). Because of its significant influence on an individual's social integration capacity, an increasing number of interventions focus first and foremost on the individual's functional capacities rather than solely on the reduction of symptoms (5).

In terms of clinical presentation and important difficulties people with SMI face, substance misuse needs to be addressed. Indeed, over half of people with an SMI will also have a lifetime substance use disorder (2, 6–8). A hypothesis that might explain this phenomenon is that individuals with SMI have a deficit in the reward circuit (i.e., neural network involving the ventral tegmental area and the nucleus accumbens) (9). This would make individuals with SMI sensitive to the gratifying effects of drugs, and so, it would be more difficult for them to resist the urge to consume (10, 11). However, it has been documented that people with SMI will use substances for similar reasons as those of people without SMI use, such as to feel more socially comfortable, to relax, to fight boredom, to feel euphoric, etc. Among the consequences related to dual disorders (i.e., SMI + substance use disorder), we find a higher rate of violent crimes (12, 13), more hospitalization, poorer compliance to treatment (13, 14), more relapses (14), a higher rate of sexually transmitted and blood-borne infections (STBBIs, including HIV) (15), a higher rate of homelessness (16, 17), more psychiatric symptoms (14, 18), poorer treatment outcomes (19), and a greater suicide rate (20) than people with a noncomorbid SMI.

### DUAL DISORDERS AND COMMON COMORBIDITIES

Concurrent disorders are often accompanied by other issues that complicate the clinical presentation. SMI is unfortunately recognized to be associated with a greater prevalence of traumatic experiences. One in three patients with SMI currently undergoing treatment has a post-traumatic stress disorder (PTSD) (2). In dual disorders, the rate of comorbid PTSD and traumatic experiences is 49% and 73%, respectively. Traumatic experiences in individuals with psychotic disorders are related to more pronounced symptoms, increased use of services, more substance use, increased incidence of physical illness, and increased high-risk behaviors (2). Group B personality disorders (i.e., histrionic, borderline, narcissistic, and antisocial) are known for emotional instability, the tendency to dramatize certain situations, and unpredictable behaviors (1). A significant portion of these individuals struggle with substance use issues. An epidemiological study reports that 78% of individuals with borderline personality disorder met the criteria for substance use disorder at least once in their lifetime (21). Individuals with group B personalities are known to show more impulsive behavior, greater mood swings, and more depressive symptoms (22). In a study on psychotic disorders, a significant proportion of patients (close to 30%) diagnosed with SMI displayed problematic personality traits associated with group B without necessarily being diagnosed with a personality disorder. Wickett et al. (23) reported the presence of these traits in 27 (59%) of the 46 individuals enrolled in their studies [the presence of traits associated in this study was determined by the MCMI-III score (i.e., score between 75 and 84)].

Fifty percent of people recently diagnosed with SMI report experiencing depressive symptoms (24). In dual disorders, a study of the different clinical correlates in SMI with data from the *National Institute of Mental Health* (NIMH) in the United States (n=1,460) mentioned that 32.2% of individuals with concurrent disorders reported having a major depressive episode in the 5 years preceding the study (18). Substance use in concomitant disorders is associated with more severe symptomatology than noncomorbid SMI (25). There is a much higher rate of completed suicides in SMI compared to the general population (147 to 750 deaths per 100,000 persons compared to 11 per 100,000 per year) (2).

### EMOTION REGULATION AND PSYCHOSIS

The study of emotional regulation is mainly based on two predominant conceptual frameworks (26). The first, Gross's (27, 28) model, defines emotion regulation as the use of different strategies to increase, decrease, or maintain an affective experience and its expression. This model is mainly used when trying to establish the usefulness and/or effectiveness of specific emotion regulation techniques in psychiatric symptoms (26). The second model, presented by Gratz and Roemer (29), is more integrative. It addresses emotion regulation in the context of the general affective functioning of the individual, subdivided into four dimensions: 1) the awareness, understanding, and acceptance of affective experience; 2) the ability to engage in a goal-oriented activity and restrain from acting impulsively when experiencing negative emotions; 3) the ability to use techniques that are appropriate to the context in which one finds himself/herself to modulate the emotional response; and 4) the openness to feeling negative emotions when pursuing a meaningful activity. According to this model, an individual having difficulty regulating his/her emotions will thus present difficulties in one or more of these dimensions (26). Studies using this model report that difficulties in all four dimensions are frequently observed in depressive, anxiety, eating, substance use, and borderline personality disorders (26), some of which are frequently associated with SMI (see the section Dual Disorders and Common Comorbidities).

Emotion regulation difficulties have also been identified as one of the explanatory factors for substance use in schizophrenia. In their model, Blanchard et al. (30) suggest that individuals with certain personality traits (i.e., negative affectivity/neuroticism and disinhibition/impulsivity) who also show difficulties in applying effective coping methods (e.g., interpersonal problemsolving) are more at risk of using substances to cope with negative emotion when encountering important stresses. This model has been partly supported by the literature (31).

Studies have shown that the use of good emotion regulation strategies leads to a reduction in the intensity and distress associated with auditory hallucinations (32, 33). It would also lead to a decrease in the likelihood of developing psychotic symptoms and prescribing medication in "high-risk" individuals (34) and a reduction in the relapse rate (35). Emotion regulation difficulties are central in comorbidities associated with SMI. Emotional regulation difficulties in individuals diagnosed with PTSD would be associated with, among other things, difficulties in functioning and more pronounced symptomatology (36). A study conducted by Ehring and Quack (37) on individuals with PTSD (n = 616) demonstrated that the severity of traumarelated symptoms is negatively associated with participants' emotional regulation abilities (i.e., greater difficulties = more severe symptomatology). The authors of the study also point out that there are no differences between individuals with complex PTSD (i.e., repeated abuse, often starting in childhood) and those experiencing "one" trauma, with regard to their abilities to regulate their emotions. These difficulties are also a central issue in group B personality disorders (38) and substance use disorders (39). Indeed, many individuals will use substances in an attempt to cope with difficult emotions, as an avoidance strategy.

Today, more and more authors place a strong emphasis on emotional processes in the treatment of SMIs such as schizophrenia (40). This phenomenon may be explained in part by the fact that the level of distress experienced is proportional to the intensity of psychotic symptoms reported (41). Studies on emotion regulation within SMI have focused primarily on the use of two cognitive strategies—suppression and re-evaluation. Suppression is a strategy where the individual tries to voluntarily limit the expression of an emotion when it occurs; it is categorized as a regulation technique centered on the emotional response. Re-evaluation is a technique in which the individual tries to modify the meaning of an event in order to change the emotional response; it is a strategy centered on the antecedents of the emotional response (i.e., before feeling the emotion) (42). As for the suppression strategy, two diverging trends seem to emerge from the studies. The explanatory model of blunted affects by Kring and Werner (43) presents this manifestation as resulting from difficulties in increasing the affective experience and a less adapted use of regulation strategies. Following this idea, researchers have identified the use of suppression strategies as one of the potential explanations of blunted affect (42, 44, 45). Other studies report that participants with SMI use suppression as much as control participants (42, 46). Studies seem more consistent with the fact that people with SMI use fewer reassessment strategies than the average person (45, 46). This strategy is known to be associated with a reduction in depressed mood and better social functioning (42). The emotional processes observed in substance use disorders suggest that the search for stimulation through the consumption of substances would aim to lessen the experience of anhedonia, an often-reported state in this population (47, 48). We can also find more recent results going in the same direction where a study reported positive correlations between novelty research, craving, and anhedonia in patients previously dependent on opioids or alcohol (49). Those correlations have been reproduced through several studies; research on the subject identifies, in a somewhat paradoxical way, that the experience of anhedonia may be a consequence of substance use (48).

Emotion regulation is central to third-wave cognitive behavioral therapy approaches (50). These therapies often encourage the use of mindfulness and appear to have encouraging results in terms of improving emotion regulation when employed with individuals with psychotic disorders (51) as well as those with substance use disorders (52). Among these approaches, some of the better known are dialectical behavior therapy, mindfulness therapy, and acceptance and commitment therapy (ACT). Dialectical behavioral therapy is an intervention initially intended for individuals with borderline personality disorder with a suicidal tendency; it was subsequently adapted to all issues involving emotional regulation difficulties (28). This therapy proposes strategies for emotion regulation according to six dimensions: 1) emotional vulnerability factors; 2) events (internal/external) leading to an emotional response; 3) interpretation of events; 4) the emotional response (physiological, cognitive, experiential aspects)…; 5) the verbal/nonverbal response and the actions taken; and 6) the impacts of the emotion felt (e.g., secondary emotion) (53). Mindfulness-based therapy is an intervention aimed at developing awareness of the present moment by taking an attitude of nonjudgment (28). Finally, ACT promotes the acceptance emotional states in order to help individuals commit to goals in accordance with their values (54). Studies support that this intervention is associated with an improvement in emotion regulation and a decrease in anxiety and depression symptoms for those with early psychosis (51) as well as those with SMI with comorbid traumatic childhood experiences (55). Third-wave treatment among users of different substance categories also produced encouraging results in which there was a significant reduction in drug use but also a better retention than in treatment as usual (56). Interventions, such as thirdwave treatments, that offer better emotion regulation strategies to people with comorbid disorders, namely SMI with substance misuse, are needed and could likely improve the individuals' lives not only by diminishing the need to use drugs to cope but also by helping decrease distress, associated with various clinical presentations.

### ACCESS TO TREATMENT

Difficulties in accessing mental health services are a major global concern, particularly in relation to drug and alcohol addiction issues (57, 58). This situation is even more concerning given the link between difficulties in receiving services and the onset use of injectable drugs among individuals already experiencing substance use disorders (59). In order to better target accessibility needs, Lesvesque and colleagues (60) suggest conceptualizing access to services in five dimensions, derived from a synthesis of the literature on the subject: accessibility, acceptability, availability, costs, and relevance of services. Accessibility refers to the importance of services being known to the population. This is particularly important considering findings that suggest that individuals with substance abuse disorders are more likely to favor familiar treatments (61). Acceptability refers to the cultural and social dimensions that must be compatible with the type of service offered (e.g., belief in the cause and treatment of diseases). Availability refers to the resources required for a facility to provide services to the entire population and to be "physically" accessible (e.g., within-territory distribution based on the density of population, flexibility of work schedules, and adaptation of the environment for people with reduced mobility). Service costs refer to the capacity of individuals to spend money in order to receive a service. Finally, the dimension of relevance of services highlights the importance of matching services to the needs of clients.

Issues regarding the availability of services seem to be one of the main barriers to access in addiction issues, particularly in relation to the problem of waiting time (59, 61–65). Studies on this matter conducted among individuals with dual disorders also report difficulties in the relevance of care provided in this population, who, when compared to individuals with a unique diagnosis of substance use disorder, appear as those being the least satisfied with services rendered due to a lack of compatibility with their needs (e.g., treatment setting for a specific disorder that doesn't accept people with substance use disorder) (66). Acceptability of care has also emerged as an important issue in this population—with the majority of individuals indicating that they prefer to manage their symptoms independently (66). In addition, individuals with dual disorders often report feeling excluded from health care services because of the dual diagnosis (mental health services do not accept them because of substance use disorder and vice versa). A preference for more personalized services, such as integrated treatments, was mentioned along with detailed reports regarding the lack of perceived usefulness of a parallel treatment focusing on a single diagnosis at a time (67).

Canadian studies on access to services seem to raise the same concerns as elsewhere in the world with a few exceptions. As the public health system bears the costs of certain interventions such as the use of opioid antagonists, it is possible that issues related to the cost of certain services may be less significant than in other countries lacking a similar structure (64). In Ontario, a report on the quality of mental health and addiction services states that individuals unable to access services reported problems of availability (i.e., difficulties with language, service hours in conflict with working hours), accessibility (i.e., not knowing where/how to get help), costs related to services (e.g., insurance does not cover certain services), and acceptability (e.g., fear of stigma related to the request for help) (62). In Quebec, a study by Champagne and Contandriopoulos (68) on the impact of the recent reorganization of health care services between 2015 and 2017 reveals a number of disturbing findings regarding the accessibility of care in mental health and addiction treatment (68). Based on the information collected in the integrated health and social service centers [Centres Intégrés de Santé et de Services Sociaux (CISS)], the organizations in charge of providing services in the region, researchers found that access to mental health services remains problematic and inadequate for the whole region (i.e., less privileged centers offer fewer services than more privileged centers). With regard to access to addiction services, researchers point out that although several centers have recently integrated detection and early intervention services, only one CISSS (center) had a satisfactory accessibility score (i.e., 79% of patients had been consulted within 15 days).

### THE SMARTPHONE, AN INCREASINGLY POPULAR TOOL

#### Assessment

We have witnessed a significant increase of people with cell phones from 2010 to 2015 (69). This phenomenon is observed in several age groups, different socioeconomic levels, and several different cultures from around the world (70). A study of patients attending hospital emergency departments reported that 70% (176/249) of individuals struggling with homelessness in the past year had a cell phone (or a smartphone—76/176, 43.2%) in their possession (71). In its annual report on the issue, the United Nations–sponsored international telecommunications union estimates that 90.3% of people in developed countries have a subscription to a mobile phone service (72). With regard to people suffering from a psychotic disorder, a survey assessing 1,592 individuals with a serious mental illness (i.e., schizophrenia, schizoaffective disorder, and bipolar disorder) reported that 72% of participants had a smartphone (73). The smartphone adaptation of mental health interventions offers several advantages that can potentially mitigate certain problems encountered by the community. It could allow the assessment of individuals in their natural environment, where some mental health issue originally emerged, instead of studying them in more artificial contexts such as a clinic or a hospital (5). Furthermore, by allowing someone to assess his/her current state (see section below) and to access support at any time (and any place) needed, this new medium could be part of the answer to treatment accessibility issues (74).

Data collection using applications can be organized in different ways. Among these approaches, the ecological momentary assessment (EMA), defined as "methods using repeated collection of real-time data on subjects' behavior and experience in their natural environments" (75, p. 3), appears as a promising method in the use of new technologies in mental health and addiction (70). Shiffman et al. have published a comprehensive record on the issue in the 2008 *Annual Review of Clinical Psychology* (75). The authors report that this method makes it possible to overcome the important stakes of memory bias (e.g., memory salience depending on emotional valence), which researchers are necessarily confronted with when relying on retrospective evaluation of a phenomenon occurring in the natural environment of the subject. They also mention that this method makes it possible to capture more precisely the variations of a phenomenon over time (for example, mood levels during the week evaluated twice a day) because it makes repeated measurements of the phenomenon in a relatively small time gap. These two factors contribute to increasing the ecological validity of the EMA (70, 76, 77). This greater validity could potentially help better understand the "risk situation–feelings of craving– consumption of substances" sequence in substance use disorders (78). Shiffman et al. (75) proposed four potential uses of EMA in research: identifying individual differences by comparing multiple groups, tracking the "natural history" of one or more topics to capture variations in phenomena across time, studying the interaction of two or more phenomena in an individual's environment (e.g., mood levels following a stressful event), and studying the temporal sequence of certain phenomena (e.g., contextual or internal factors leading to substance use). By offering the possibility to perform assessments on a regular basis or according to the events under study, the EMA is flexible enough to adapt to the study of several psychological phenomena such as episodes of craving in substance use—an event occurring in a small time frame—or general mood that often requires multiple assessments (75). Much research in the field of mental health applications has incorporated this approach. Researchers working among adolescents have reported that using this method would produce valid results in the assessment of symptoms, environmental contexts, and coping strategies used in real time by users (79). A study by Comulada et al. (80) including adolescents with substance use disorders (13 to 18 years old) was able to clarify the external and internal cues related to drugs and alcohol consumption. With the help of an application-based EMA, these researchers were able to establish that, compared to other drugs, alcohol consumption occurs mainly on evenings and weekends. In the field of SMI, research using this method has suggested a link between the environmental context and the intensity of hallucinations (81) and a greater reactivity to daily stresses between individuals at risk of developing psychosis (82).

#### Intervention

Following the same principles as EMA, interventions using smartphone applications or ecological momentary intervention (EMI) are considered interventions in the individual's everyday environment (83). Although the study of these interventions is still in its infancy, researchers have reported encouraging results for the use of EMI for several health issues, such as weight loss (84), reduction of anxiety levels (85), reduction in the number of cigarettes smoked (86), and increase in physical activity (87).

The National Institute of Mental Health (NIMH) in the United States identifies six categories of mental health apps (74):

Growing evidence tends to support these different applications as effective methods of prevention and intervention (70). Among other things, these apps have already been associated with a reduction in depressive symptomatology and anxiety and an improvement in substance use problems in several studies (88). However, it is important to note that this field of research is still young; the majority of research published in this field are pilot studies with no comparison group or randomized studies [Randomized controled trials (RCTs)] that have not yet been replicated (89). Recent research has also reported that this intervention format is well received by adolescents dealing with mental health issues (90, 91) or physical health issues (92).

In the field of SMI, a literature review by Firth and Torous (93) identified five applications, evaluated in seven separate articles those apps were primarily designed to promote self-management of the disease. The authors report that the majority of applications were very well received by participants, with an estimated average use of 85% of the days in which the studies were conducted, 3.95 times per day. It also states that people at risk for a psychotic episode and those who just experienced their first psychotic episode were most likely to use the app. Another study involving 33 individuals with SMI or schizoaffective disorder assessed the feasibility and acceptability of the FOCUS app, an application offering the possibility of obtaining clinician assistance, and reported positive results going in the same direction (use: 86.5% of days, 5.2 times per day) (94). An original aspect of this study was that the design of the application took into consideration the cognitive impairments of the targeted population (95). A recent study by Schlosser et al. (96) has also reported encouraging results on the use of the PRIME application (i.e., personalized real-time intervention for motivational enhancement) among individuals who have recently experienced a first psychotic episode. Aimed at fostering goals for better health, quality of life, interpersonal relationships, and greater productivity, PRIME invited participants to select one of 36 life goals (e.g., improve my relationship with my family) that they wish to pursue. Shortterm goals derived from life goals (e.g., doing a fun activity with a family member) were then suggested to the participant. The application also allowed users to send messages to experienced clinicians and other users of the application on an online platform for advice or support to achieve their goals. Researchers report that individuals who used the app over a 12-week period significantly improved their sense of self-efficacy and motivation and had a significant reduction in the severity of their depressive symptoms and defeatist thoughts (96).

Encouraging results have also been seen for applications targeting disorders that are often comorbid in SMI. In September 2018, the Food and Drug Administration (FDA) authorized the marketing of the first application designed to assist in the treatment of substance use disorders, the application reSET. It is the first application of its kind available only under medical prescription (97). The application consists of a contingency management module of 62 exercises aiming at enhancing personal well-being without resorting to substance use (i.e., how to improve communication, mood management, prevention of transmission of sexually transmitted infections, …). In order to facilitate monitoring, the user's activity on the application is listed on a web page accessible to the physician (97, 98). The validation study of the application, performed with 507 people, demonstrated that the use of the application was associated with more days of abstinence and a lower rate of attrition than in the treatment-asusual condition (98). It is important to mention that this study, which served as justification for the approval of the application by the FDA, was performed on a desktop-based intervention, which was subsequently adapted to the format of a mobile application (97, 98). In the adult cannabis-using population, a mobile app called Stop-cannabis was developed in Switzerland by one of the authors (YK) and colleagues and reported more than 73,000 users in 4 years (currently about 1,300 active users and 13,000 sessions per month). Based on the self-determination theory, this application aims to promote autonomy, competence, and relatedness as part of a process to reduce cannabis use. Following these principles, the various interventions offered by the application are based on brief intervention in substance use disorder, motivational interviewing, and the principles of relapse prevention for substance use disorder (99). More specifically, the application first gives access to a series of psychoeducation modules on the effects of cannabis withdrawal and suggests alternatives to consumption for a craving episode (e.g., call a loved one, entertain yourself on social networks). Following the principles of motivational interviewing, the application allows the user to identify the advantages and disadvantages of stopping cannabis use. The home page also displays several cues to facilitate cannabis cessation (i.e., the number of days without consumption, the amount of money saved due to the cessation of consumption, and the possibility of purchasing rewards after a certain number of days without taking cannabis). In 2016, an analysis of data related to 22,000 users showed that they compiled 722,000 app sessions, with more than 30% of people having more than 6 sessions. Furthermore, a subgroup of 10% of users had performed 20 or more sessions. In terms of satisfaction, around 70% of them reported daily use of the app, and 80% reported that the app helped them to stop or reduce cannabis consumption "a little" or "a lot" (99). The Stop-cannabis app is currently under validation, and preliminary results demonstrate its feasibility and potential for cannabis adult users wishing to stop using*.* This application combined with an EMA program is now under study with adolescents with dual disorders (100). Young cannabis users (mean age: 20 years) who followed two sessions of motivational enhancement therapy combined with a mobile intervention designed to prevent relapse have reported a reduction of the craving sensation and a decrease in the amount of cannabis consumed (101). Furthermore, several cannabis-related psychoeducation online platforms were launched recently, but the evidence on their effectiveness is limited, as they have rarely been properly evaluated with regard to the content quality (102). These results are particularly encouraging for some countries such as Canada (the first G-7 country to legalize cannabis), knowing that the profiles of cannabis users in this country are quite different from those of users of other substances, with most cannabis users being under the age of 20 and still in high school. This profile should influence the content of the treatment and the manner in which the treatment is offered (103). Many youths will wait years before deciding to seek professional help for their cannabis use. This is partly due to the stigma associated with seeking professional help, as well as the fact that it can take that long for youths to realize that their cannabis use might be a problem.

In alcohol-related problems, researchers using an application designed to provide support to people with alcoholism (Addiction—Comprehensive Health Enhancement Support System or A-CHESS) were able to partially predict the number of days of consumption based on the level of use of the application by the user (i.e., number of times spent on the application, number of pages viewed) (104). As in the case of the Stopcannabis application presented above, the design of the A-CHESS application was based on the model of the self-determination theory. In trauma-related conditions, Possemato et al. (105) evaluated the effectiveness of an application (PTSD Coach) in reducing the symptoms associated with trauma in groups of veterans diagnosed with PTSD separated into two conditions (application with or without clinician assistance). The application has been associated with a decrease in symptoms under both conditions, with a significant benefit for the clinician-assisted condition. Other studies also report positive outcomes with the use of mobile applications for the management of different mood disorders (106–108).

Some recent research in mental health apps has evaluated the effectiveness of interventions that promote emotion regulation. To date, two applications were developed for a population with borderline personality disorder. EMOTEO, an application developed by a research team at the University of Geneva, was developed with the aim of providing emotional support during crises occurring between consultation sessions with the health care team (109). It allows the user to use mindfulness or distraction exercises according to the level of distress that has been reported initially using a distress scale ranging from 0 to 10 (i.e., mindfulness exercise when the tension is between 1 and 6 and distraction exercises when it is between 7 and 10 following the idea that users in intense emotional distress don't have a lot of resources to focus on a more complex exercise). The user is invited to report his/her level of distress once again after completing the exercise. The levels of distress that have been reported over time are reported on a graphic accessible from the main menu. The application also allows a direct call to emergency services if the app user feels the need to make one (109). DBT Coach is an application designed to promote the implementation of new skills acquired in therapy in the natural environment of the individual. More specifically, it aims to help the user develop the competency of the opposite action, a technique taught in DBT that consists of acting in a way that neutralizes a negative overwhelming emotion (110). In order to suggest an opposite action adequate for the state of the individual, the application first asks the user to evaluate the intensity (on a scale of 0 to 10) and the quality of the emotion felt. After this information is entered, the program asks the individual whether or not he/she is ready to change the emotion. In the case of a positive response, the application will ask the user to indicate a specific action urge that he/she feels in connection with the reported emotion and will then provide a list of opposing actions that can be performed in response to this emotion. A negative answer will show windows where the user can indicate the "pros" and the "cons" to changing an emotion. Both applications have shown promising results in reducing the distress associated with a dysphoric mood, in reducing the "urgency to consume" ("craving"), and in the improvement of the depressive state (109, 110).

Mobile apps are increasingly recognized as effective tools for facilitating behavioral change (111). Their practical format facilitates the implementation of new strategies directly in the environment where their difficulties have emerged (5). Emotion regulation applications help individuals manage the different features of an emotional reaction when they occur in their environment. Following this principle, several mood-enhancing applications have been shown to be effective in reducing anxiety levels (e.g., 88, 112, 113). and improving depressive symptoms (e.g., 107, 108, 112, 114), two emotions known to increase the risk of relapse in substance use (115, 116). Applications could then potentially reduce the risk of relapse by aiming to stabilize the emotions associated with it.

#### Challenges and Limitations

Issues of security and privacy of applications are a major barrier to the acceptability of mental health applications, particularly when it comes to the transmission of non-Internet information (117). Not only does the information collected have the potential to be detrimental to the individual; applications may record a substantial amount of data on the individual [e.g., visited environments that have been recorded through geo-location system (118)]. Studies report very few mental health applications with an adequate privacy policy or secure data transmission methods (119–121). Huckvale et al. (122) conducted a systematic assessment of the applications presented on the English National Health Service (NHS) website, a public health organization with a mandate to ensure compliance with data protection regulations in England (122). Applications were evaluated based on their compliance with data collection/transmission/storage guidelines, confidentiality, privacy policy content, and the adequacy of these policies for the application's actual behavior. One of the main findings reported by the research team concerns the high variability of the security level of the applications. Only one-third of the apps available had a confidentiality policy, which, in most cases, was incomplete (e.g., no specification on the use of data by a third party or incomplete explanations of the process for requesting changes to registered data as allowed by law). The study also reports that a large number of applications stored and transmitted unencrypted personal information. In light of these findings, the researchers point out that enforcement accreditation by a government agency does not guarantee the security of the data that will be recorded and invite users to exercise caution. Some authors also link the lack of consistency in the security of applications to the fact that government regulations in this field are sometimes ambiguous—e.g., an application pretending to cure a condition will not be subject to the same level of evaluation as an application designed to "improve mood" (89). Unfortunately, policies protecting app users are not rigorously being applied today and are lacking information in some important areas such as the use of data by a third party (121). As a result, users are encouraged to exercise caution when choosing a mental health application (74).

The speed at which technology is evolving today makes it difficult to accommodate the empirical validation process, which always requires a certain amount of time (74). Moreover, several issues regarding the validation of EMA tools are still in need of attention. First, although the EMA is more suitable for capturing intra-individual differences over time, this is not always the case for recall-based questionnaires (75). One challenge in this situation would be to adapt and validate tools compatible with the characteristics of the EMA. Furthermore, very few studies have examined the psychometric properties of tools used to collect information on mobile phones. These properties could potentially differ from those used for more traditional questionnaires, because they are not always used in the same context—e.g., users could fill out the questionnaire on their phone while they perform other tasks at home (123). Finally, it is possible that the small number of items generally used in EMA tools may produce limited results where we only scratch the surface of a particular phenomenon.

It is important to mention that the use of mental health apps in a population presenting a substance use disorder carries a risk of cross-dependence (124). Several studies have found similarities between certain behaviors associated with the problematic use of the Internet (i.e., gambling, compulsive pornography viewing) and substance use problems, including 1) unsuccessful attempts to reduce or put an end to the problematic behavior, 2) concerns (feeling of craving) leading to problems of functioning, and 3) continuation of behavior despite deleterious effects (124–126). There is also evidence of an association between behavioral addiction (i.e., pathological gambling, compulsive buying, Internet addiction, work addiction, and exercise addiction) and problematic use of mobile phones in youth (127).

### CONCLUSION

The treatment of individuals with SMI is often long and complex, in part because of the important functioning impairments but also because of the clinical presentation. The clinical presentation is often complicated by the presence of many comorbidities, such as substance use disorders, which are more often the rule than the exception. As in other mental health conditions, individuals with SMI and comorbid substance misuse often face accessibility difficulties for treatments offered in mental health settings. The mobile phone could potentially be part of the solution to this issue by providing immediate access to strategies, when needed. Studies on this new form of intervention method report encouraging results for several psychiatric conditions. However, more research with comparison groups is needed to determine their clinical efficacy with greater certainty. In terms of intervention techniques, treatments aimed at improving emotion regulation have been shown to be effective for people with different diagnoses, including SMI and substance misuse.

In this perspective, an intervention promoting the development of emotional regulation skills for a population with comorbid SMI and substance misuse could potentially facilitate access to care and promote better management for those individuals. Our research team is now working on the development and evaluation of such an application, focusing on emotional regulation, that takes into account the specific characteristics of this population by applying the rules for designing applications for persons with cognitive deficits (95). The application for dual disorders, called Chill Time, includes a module dedicated to assessing distress and a module offering different intervention strategies primarily based on cognitive behavioral and third-wave strategies for emotion regulation. The application consists of 20 exercises divided into four categories: 1) cognitive, 2) emotional, 3) behavioral, and 4) spiritual strategies. Each of the strategies employed by the user is evaluated on its perceived usefulness once the exercise is completed. The application is currently under final development and validation. Should the results be positive, such an application may increase access to services and help link actual *in vivo* strategies with therapeutic outcomes, as assessed

#### REFERENCES

by clinicians. The assessment module includes a notification system that is similar to what can be observed with other social network apps; two alerts per day in total will be sent to the user. Once the notification is opened, the user will be redirected to the application, where he/she will be asked to rate his/her distress on a scale of three anchor points (i.e., good, neutral, not good). Should the response be neutral or negative, the user is redirected to a list of two exercises he/she could perform to emotionally self-regulate (stemming from two different categories). The two suggested exercises are chosen on the basis of the user's past evaluations of the strategies' usefulness (the exercises offered are initially randomly offered until the application has collected enough information on the preferences of the users).

Mobile applications have the potential to assist people with dual disorders in using strategies between treatment sessions without having to rely on their memory. Future studies are needed in order to demonstrate their efficacy and to offer profiles of emotional strategies used and their impact on substance misuse. Although multiple applications are being developed, only those with strong empirical support should be recommended and used.

### AUTHOR CONTRIBUTIONS

AP did most of the writing and research. The other three authors (TL, SP, YK) contributed to the article by writing and editing the sections corresponding to their area of expertise in collaboration with the first author.

p. 1–48. Retrieved from http://www.hqontario.ca/portals/0/Documents/pr/ theme-report-taking-stock-fr.pdf

**Conflict of Interest Statement:** One author (SP) is the holder of a grant from Otuska Pharmaceuticals unrelated to the topic of the current paper. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

*Copyright © 2019 Pennou, Lecomte, Potvin and Khazaal. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.*

# Recovery Attitudes and Recovery Practices Have an Impact on Psychosocial Outreach Interventions in Community Mental Health Care

#### *Emmanuelle Khoury\**

*École de travail social, Université de Sherbrooke, Sherbrooke, QC, Canada*

#### *Edited by:*

*Sebastian von Peter, Medizinische Hochschule Brandenburg Theodor Fontane, Germany*

#### *Reviewed by:*

*Andrew Clifton, De Montfort University, United Kingdom Louise Penzenstadler, Geneva University Hospitals (HUG), Switzerland*

*\*Correspondence:*

*Emmanuelle Khoury<EMAIL_ADDRESS>
#### *Specialty section:*

*This article was submitted to Public Mental Health, a section of the journal Frontiers in Psychiatry*

*Received: 07 September 2018 Accepted: 17 July 2019 Published: 13 August 2019*

#### *Citation:*

*Khoury E (2019) Recovery Attitudes and Recovery Practices Have an Impact on Psychosocial Outreach Interventions in Community Mental Health Care. Front. Psychiatry 10:560. doi: 10.3389/fpsyt.2019.00560*

The most recent mental health policies implemented in the province of Québec, Canada, have emphasized recovery-oriented mental health practice. Part of this impetus has resulted in significant importance placed on the development of community mental health models in the public health system. The forms of community mental health programs have evolved considerably over time in Québec but are largely inspired by the evidencebased model of Assertive Community Treatment (ACT). However, if mental health policies and programs in Québec are now emphasizing the role of community mental health, it is also clear that actors on the field are implementing the evolving practice paradigms that dominate our mental health policies, such as recovery, participation, citizenship, in a variable way (1, 2 ). This article presents an ethnographic inspired research study conducted in 2014 and aims to contribute to the understanding of how recovery-oriented mental health policies are understood and implemented in an ACT team in downtown Montréal, Québec. With the aim of developing integrated knowledge on the issue of recovery in mental health and the conditions it presupposes, this research draws on field experiences from various actors, including service users with severe mental health problems, typically with concomitant disorders and complicated by substance use and/or living in a situation of homelessness. Using a critical constructivist approach, the research sought to a) explore how participants (stakeholders, users, and psychiatrists) achieve their social order; b) understand the meaning of recovery in mental health for participants and the actions associated with recovery as a process or as a practice; c) apprehend the potential of community interventions to connect the individual to the collective. The results indicate that the (over)use of medicolegal tools and the unchanging conception of "madness" represent obstacles to the sustained development of interventions centered on the person, his living conditions, and his recovery. Nevertheless, many interactions between service providers and service users indicate the potential for emerging recoveryoriented practice interventions, particularly when those interactions are based on positive and egalitarian conceptions between service providers and service users that led to the development of spaces for the co-construction innovative practice approaches.

Keywords: recovery, community mental health, attitudes, co-construction, ethnography

### INTRODUCTION

The concept of mental health recovery is the dominant organizing principle for public mental health services in many countries (1). This has resulted in important changes in the strategic direction and in the practice guidelines of mental health delivery systems. For example, recovery-oriented practice guidelines (2) in Canada stipulate that recovery "occurs in the context of one's life" (p. 38) and points to the imperative need for mental health professionals to consider and act upon social determinants of health. The literature has supported the idea that, although an individual will go through the process of recovery, professional intervention can facilitate this process (3–6). This requires certain critical values focused on egalitarian and relational attitudes (6), hope, implication, and relationships (7) that are supported by both training and organizational structures (1). The integration of mental health recovery as an approach and philosophy underlying mental health policy at an international level underscores the importance of the recovery concept; it is process oriented, person focused, and shapes governance structures toward social inclusion, quality of life, citizenship, and participation. However, there are documented difficulties in implementing a recovery-oriented practice approach (1, 8–11) that has led to misapplications, misunderstandings, and critiques (12, 13).

In Québec, mental health policies and care (Mental Health Action Plan 2005–2010; 2015–2020, hereafter MHAP) have evolved with an impetus to develop recovery-oriented community mental health teams, such as Assertive Community Treatment (ACT). Part of the continuum of mental health reform, community mental health care offers the possibility to avoid potentially stigmatizing psychiatric care by placing the person and her living environment at the center of care services. In Québec, ACT teams were developed with this care logic but also with a logic of cost efficiency (14–16).

The ACT program is a model that was developed within the walls of a psychiatric institution as an alternative to hospitalization in the context of deinstitutionalization; it is defined as providing round-the-clock, individualized psychiatric services in a person's home or community (17). However, it has a history of coercive and intrusive interventions that are almost singularly focused on pharmacological adherence to manage symptoms (18, 19). The objective of ACT is to provide comprehensive outreach in the community where service users can access the same type of treatment team they would access if they were in an inpatient setting. Elaborated in the Québec landscape, the ACT program aims to help people with serious mental health problems, often with substance use disorders or concomitant disorders, develop their individual competencies. The objective is to promote their autonomy and social integration by shifting (20) psychiatric treatment and psychosocial follow-up out of the hospital and into the individual's community [Gélinas, 1997, in Ref. (18)], particularly through supportive housing and targeted work placement programs.

The aim of this study was to shed light on the interactional experiences of providing and using services from an ACT program, particularly in an urban setting, wherein service users presented with complex mental health and social problems, including dual diagnosis for substance use and concomitant disorders. In Québec, the Centre for Excellence in Mental Health regulates and evaluates the ACT teams.<sup>1</sup> However, until now, there has been very little knowledge regarding the daily interactions, actions, and relational dynamics that support recovery within an ACT team, despite findings that point to the importance of social processes and social dynamics in reinforcing a recovery culture (1, 21). Based on these previous findings, the hypothesis was that the relationship between service users and service providers would be primordial to reports of subjective recovery journeys, and that service providers would capitalize on the proximity of their interactions to surmount organizational constraints when intervening with complex issues.

I conducted a critical ethnography at an urban ACT team whose service users experienced serious mental health problems combined with complex social problems, such as poverty, isolation, and gentrification. Many service users also had concomitant addiction disorders, and the professionals on the field had to adapt their interventions and recovery perspectives *in situ* to respond to the particular needs and aspirations of this population.

#### MATERIALS AND METHODS

#### Methodology

Critical ethnographies are a way to provide an informed reflection based on real-world contact with mental health service users and providers in highly marginalized and simultaneously gentrified urban areas for a sustained period. A key strength of ethnographic case studies is the ability to tease out the underlying value systems of the specific organizational cultures and their contexts, which can then provide key lessons to understand other situations (22). Its questioning of the relationship of social order and social structures and its methods of "reconstructing social reality by privileging multiple voices" (23) are techniques indispensable to describing and explaining relationships between people and systems within the larger political, economic, social contexts (24). At the same time, critical ethnography is considered to be a methodology that refuses to separate theory from methods (25), thereby offering a way for professionals to become "more consciously aware of how they take up their professional authority in managed mental health care contexts" (26, p. 173). Moreover, ethnographic inquiry results in not only a "thick description" (27, p. 10) of the culture being studied but also an inductive analytical strategy that requires the researcher to uncover relationships in the context of the observational and interview data. I adopted a cross-paradigm framework, including Healy's (28) conceptual model of critical practice that speaks to the importance of context and power relations in intervention construction and on Garfinkel's (29) ethnomethodological focus on the interactional and *in situ* nature of interventions. The use

<sup>1</sup> The Centre's Web site specifically notes that the services of these teams are intended to respond to service users with severe mental health problems who may also have concomitant addiction disorders.

of multiple frameworks is coherent with qualitative research and enhanced the research to "to see in new and different ways what seems to be ordinary and familiar" (30).

The ethical considerations specific to ethnography were considered, and they were attended to through a consistent reflexive stance and structured journaling. Although Husserl's notion of "bracketing" and putting aside historical and cultural assumptions to attain objectivity is vigorously contested (31), the reflexive ethnographic researcher can acknowledge these assumptions to be more thoughtful, critical, responsible, and informed of potential biases, expectations, and judgments.

#### Sampling and Data Collection

I was on site for 3 days a week over the course of 7 months engaging in participant observation. The interview component consisted of six interviews with service users and 12 interviews with health and social care professionals, including two psychiatrists, three nurses, four social workers, two psychoeducators, and one criminologist with years of experience ranging from 6 months to 10+ years. The service users who participated in the critical ethnographic study had been involved with the program from 1 month to 5 years. Although only six service users were interviewed, the care trajectories of approximately 20 service users were followed in observation and through access to their case files. During the study period, I observed service providers accompany two service users to a long-term addiction rehabilitation facility; one service user was hospitalized against his will after a substanceinduced psychotic episode; one service user's intervention plan focused around his debt accumulation for the purchase of illegal substances; and another was concurrently followed at the methadone clinic. I used a strategy of triangulation<sup>2</sup> of sources by using three data collection techniques—participant observation, document analysis and case file analysis, and individual interviews.

#### Measures and Analysis

Consistent with a qualitative tradition, the data were analyzed using the NVIVO software and by using techniques of thematic analysis that began with an initial open coding phase. Understanding the concept of recovery from the subjective perspective of participants was achieved not only through inductive coding but also through identification of i) the influence of agency and policy contexts on practice, ii) the analysis of practice descriptions, and iii) recovery-oriented perspectives of the implementation of the mental health policy. The analysis considered microlevel dimensions of recovery, such as social interactions with friends, family, and neighbors, mesolevel dimensions, such as social interactions with professionals and institutions, and macrolevel dimensions, such as community engagement and participation. The ethnographic component of the 2014 study meant that data collection and analysis were simultaneous. Analysis was very tangled up with every stage of the research process (22).

Funded by the *Fond de recherché du Québec-Société et culture* (FQRSC) doctoral award, this ethnographic study is governed by deadlines respecting ethics and integrity. The study received approval from the Université de Montréal's Research Ethics Board and Université de Montréal Health Centre's Research Ethics Board. All of the participants signed consent forms and kept a copy of the signed agreement. The informed and free consent of participants was assured.

### RESULTS

The everyday world of this urban ACT team is dynamic and in action. My findings related to the subjective participant meanings and accomplishment of recovery-oriented mental health care that are embedded in this dynamic active state.

The thematic analysis underscored three key elements to the interactions and actions that are derived from the social processes and organizational structures of this ACT team. These three elements, flexibility in practice, complexity of practice, and relationships in practice, are located at the intersection of difficult practice moments, which I refer to as "practice tensions." These three elements sum up the particular nature of the culture of intervention of an urban ACT team with a population experiencing complex mental health problems and social problems as well as the meanings and actions involved in recovery-oriented attitudes and practices.

#### Flexibility in Practice—A Key Component of Recovery-Oriented Practice

Major differentiating factors of the ACT team compared to other specialized mental health care teams are the flexibility and intensity that are hallmarks of the ACT fidelity scales. What do these descriptors look like in real life? The organizational structure of ACT provides a good foundation for service providers to be flexible with their timing and schedule and for all service providers to influence the overarching team perspective on care. That means that when they visit a service user for a coffee, to deliver or administer medication, or for a visit, they can take as long as the service user needs. Sometimes this is 5 min, and sometimes a simple medication delivery becomes a 30-min intervention. The ACT program's continuity of service through its connection to a parent institution is a key factor ensuring flexibility and clinical autonomy, as per one of the psychiatrists who explains:

*It's clearer and clearer in the literature that ACT is a flexible and adaptable platform … because we are attached to a hospital, we can ensure continuity … we have the privilege of direct admission, we don't need to negotiate…*

Thus, the notion of flexibility remains rooted in a hospital-centric approach where it is understood by the link with admission units and the psychiatric emergency. The traditional case management model does not seem to provide a context for making sense of the construction of interventions

<sup>2</sup> Guba and Lincoln, 1985;Quivy and Campehoudt, 1995.

that can influence community links, social cohesion, or social participation.

Service providers described tensions in their desire to develop interventions that are recovery oriented and the current organizational framework, which is influenced by a rigid, institutional design. However, the ethos of this team, that is, the way it believes that service users should behave, develop, and feel (27), influences the meaning prescribed to interactions and influences the flexibility that is promulgated regarding both through relationship building and within the organizational framework.

The intimacy that both the intensity and the intrusiveness of ACT programs requires can be potentialized to gain in-depth knowledge and trust with a service user. This is particularly supportive of recovery-oriented interventions with service users who have complex social problems or present with addiction or concomitant disorders. As explained by one service provider:

*That's the difference, it's not in an office … being at a client's home, it's intimate. The home can tell you a lot about a client. We have access to things that you wouldn't access in an office meeting.*

Flexibility exists in the professional autonomy experienced by service providers. Although the choice of practice approaches is somewhat regulated by the Centre for Excellence in Mental Health based on fidelity to the TMACT scale (32), many innovative interventions are constructed *in situ* to respond to the diverse and complex needs of service users. These include street-level work, such as meeting a service user at a downtown bus station when she returns from an addiction rehabilitation center or meeting a service user daily in his home to structure his budget and his daily activities to reduce his recourse to debt accumulation and substance use.

For example, this particular ACT team demonstrated its harnessing of the flexibility of the ACT program to develop practices that are not included in their fidelity scales and evidence-based mandate. These attitudes and practices led to the development of new services within the team, such as a mini-team to intervene specifically with a homeless population experiencing mental health problems. This new way of working, above and beyond their mandate of ensuring supportive housing and medication adherence, is an example of flexibility in intervention, wherein recourse to medicolegal tools or pharmacology was not perceived as the only option for service providers.

The personal influence that individuals have on how flexibility is defined should not be underestimated. Regardless of that, there is an important inescapable rigidity in the tools that are available to the team. These are mostly related to the way medication and a reductionist biomedical perspective continue to have a structuring role. In many ways, this is an elite team of mental health professionals who have experience, knowledge, and a significant amount of power as they enter into people's homes and communities. The notion of flexibility in practice is an element in tension because, despite the community location, there are few community-focused interventions. The choice of intervention is constructed according to the subjective values of the actors in action rather than by the technical platform of the ACT model that is physically located in a community-based setting.

#### Complexity of Practice—A Key Component to Addressing Authority and Autonomy in Practice

The complexity of practice is evidenced as a situated action wherein the tensions in the position of ACT as a specialized, elite, and experienced team and the subjective concerns regarding coercion, authority, and risk management are explicated. Situated action is at the heart of an ethnomethodological and interactionist research perspective because it emphasizes how participants use common-sense practices to produce, analyze, and make sense of each other's actions and circumstances.

This elite team also expressed feelings of powerlessness at being the end of the line of care. Court orders offer an upper hand in negotiations to ensure compliance and treatment. As one social worker explained:

*This is the last stop in services for these people … I think once they are back on their feet, then they are ready … but it's difficult to establish a relationship, we represent an authority that reminds them of their illness … the people followed here are very unstable … We need court orders.*

The program priorities of both avoiding hospitalization and maintaining autonomous housing as well as the emotional need for service providers to alleviate their feelings of helplessness sometimes led to service providers attending to clinicaladministrative priorities rather than person-centered clinical impacts. As one service provider told me, "If the person decompensates, we'll look like clowns." The tension for the service users is that they are relieved to be avoiding multiple hospitalizations in collaboration with the ACT team but they also reported experiencing uneasiness with the supervision and control of their actions and interactions.

These statements belie the control and surveillance that service providers feel are necessary to accomplish their roles, manage risk, and interact with service users. One of the service providers, Robert, explained that he justifies the imposition on service users that his role as an ACT service provider requires by framing it as a way to force collaboration. Other service providers echoed the sentiments that "there is no choice with an ACT clientele but to be coercive." The team lead offers a softer approach to the tension between coercion and collaboration. She explains that the coercive nature of the ACT program, engrained into its very *raison d'être*, requires the service providers to be "strategic in their negotiations [with the service user] so that the outcome is in the service user's advantage." This is often accomplished by "striking a deal" with the service user and avoiding legal orders. For example, there was one situation in which there was the possibility for a young adult, who came to the service when she was living on the streets and using heroin, to live in stable institutional housing. Specifically, the team agreed that they could offer this service user less frequent visits and more weekly money to help her feel secure in exchange for her accepting the housing agreement.

The central implication of this element, complexity in practice, is that recovery actions and interactions are dependent on the conception the team has of the service user, the subjective service provider beliefs, and the understanding of risk management that is at the heart of daily decisions of stakeholders. But discursive processes, the team culture of dialogue, and social cohesion among service providers seem to be protective factors in the evolution of risk analysis and subsequent measures put in place. I observed a very cohesive team built by the service providers and the psychiatrists who share their knowledge and concerns informally in the corridors but also officially in daily meetings. Internal decision making is horizontal, and service providers themselves often challenge the dominant medical discourse. They consciously avoid using diagnostic language.

#### Relationships in Practice—A Key Component to Building Trust, Hope, and Implication

It is not surprising that service providers' subjective experiences affect their affiliation and affinity toward certain service users. Therapeutic alliance implies getting to know persons for who they are, their interests, their life stories, and thus going beyond a reductionist description of symptoms. One service provider explained the centrality of the therapeutic alliance:

*A relationship. When we have a relationship with a client, we have everything. The rest is candy.

Service providers and service users made the assertion that focusing on symptoms and medications and even reverting to hospitalizations are "the easy way out.'" The varying complexities of social scenarios remind the team lead, a social worker, of the role of psychosocial elements in the vulnerable and marginal situations that the service users find themselves in. The team lead suggested that her professional standpoint, which is a result of her professional and personal experiences, has made her realize that:

#### *We need to flirt with risk … I am not afraid of madness and so I have access to madness when I meet with people.*

The relationships, the therapeutic alliances, the community housing, and the social networks that are developed in the ACT structure are not created only within the confines of the four walls of the ACT office. They are also created and developed on the street, in the bus, in cars, in apartments, in short, in circulation in the community. These relationships that are amicable and sometimes even affective are bound by the professional role of the service providers. These are institutional relationships that are uniquely joined at the locus of the human condition, juggling the reality of implicit control through medication and explicit trust building predicated on the acceptance and facility with madness. The affinity among actors is woven by the social links between service providers and between service providers and service users. Although some participants pointed to the long-term follow-up that is accorded within an ACT program as a necessary element to relationship building, this element also exposed tensions regarding sustainable and authentic social integration.

One psychiatrist on the team expressed some distress at having to juggle the biomedical paradigm and more progressive personcentered approaches. However, she suggested that the coercive practices, which are anchored in the traditional psychiatric philosophy, are a status quo that must be worked around rather than revoked:

*How do we deal with the coercive aspect of our job … I find it hard … It is a challenge. I do not want to harm anyone. It is a clientele that is not always easy, the risk is ultimately complex.*

The ACT team, through their frequent contacts with the service users and, for the most part because of the sincere interest from the service providers, has succeeded in initiating a trust relationship with most participants. This also serves to understand, respect, and recognize a person's fears or concerns. The ACT program activities provided a context in which interventions and interactions among actors take place in intimate settings, such as the service user's home. The variety of places and spaces for intervention leads to a permutation of many aspects of the lives of the users; I observed that often the service providers' role paralleled that of friend and family. This leads to a quality of interaction based on special attention to people's lives and circumstances. Although the intimacy of home visits is often experienced by the service user as an intrusion and management of her private space, it was also welcomed by many and qualified as "human" and "calming."

The tension lies in the location of these interactions being both a unique opportunity to have access to the singular experiences of the service user but are also obstacles to integration and to actual inclusion in the community. The results demonstrate that the ACT team has become a social network for users. However, clear professional boundaries ensure that the development of this social network is unidirectional, empty of the reciprocity found at the core of human relationships, reducing the interaction to a simple service offer.

### DISCUSSION

In the present research, my aim was to examine both the understandings and affinity to recovery-oriented practice and to understand how and if it is constructed by service users and services providers. The results show that one of the strengths of the constant tug of war the ACT team experiences, whether it be about what they do with the flexibility the program accords them, or how they use tools and professional autonomy to mobilize community resources, or how they respond to social inequalities, is that the dialectic is not suppressed. Although social change is not addressed or mandated, specific microlevel interventions are distinguished based on the service provider's relationship with the service user and the assessment of a service user's potential for personal change.

In the ACT team, every action and interaction are parts of a hybrid service culture that is on the one hand person centered and flexible and on the other hand symptom focused and coercive. Once a strong therapeutic alliance has been created in a professional-patient dyad, and in the ACT team it is often on the premise of developing a social relationship, then the line between a paternalistic interaction and one that is egalitarian and potentially collaborative is blurred. The authority inherent in the role of professionals and particularly in their role as professionals in an ACT team is not lost on the service users. One service user, whose relationship with her service providers has been mitigated by their intervention plans that include inpatient addiction rehabilitation services, explains the tensions that she experiences with the professionals who are at once personable and warm and also hold immense power and control over the lives of service users.

The space and place used by the ACT team can have paradoxical impacts on the multiple actors. The occupation of these spaces at different times and in different circumstances gives rise to tensions that are often invisible to the official structure of the program. The social roles that are played by the actors in an ACT team are varied and numerous, echoing the seminal discussions by Goffman (33, 34) that a group, or in this case a team, plays a central role in the actions and interactions of individuals within that team. Once they know the established roles and rules of play, the service providers "improvise" individual actions that are to be chosen based on the effect that they might have on others.

#### Proximity, Intensity, and Recovery

The different ways of engaging in relationships in close proximity make up the specificity of ACT interaction and are often referred to by the service providers as "accompaniment." These actions and interactions are not framed by clinical tools or clinical guides and are often context and person dependent. They can range from feeding a service user's cat when they are hospitalized to helping them move apartments or to buying groceries and cooking supper together. For service users, the hope and time that are offered through the structure of the ACT team are important for their recovery process specifically as it relates to social relationships.

The service provider-service user relationships, which are embedded in a professionalism that maintains strict boundaries, do not erase power inequalities and the specificity of the belonging to a certain group (service user, professional, psychiatrist). This division is a major challenge for the ACT team as it works toward improving the quality of life, and supporting a life of quality, for service users in the community. Service providers generally concurred that they focus on the observable mental health difficulties, whereas other teams, groups, or services will work in partnership with them to manage and support in other aspects of the person's life.

#### Two-Tiered Recovery Practice

This study found that recovery-oriented practice is accomplished through a form of institutional accompaniment that is developed based on a singular, intimate knowledge of each service user and through a negotiation of outcomes for groups of service users. Service providers believe in the general idea of recovery as per my observations and the interviews, but the construction of recovery-oriented practice is more elusive. There are paradoxes and complexities specifically related to institutional accompaniment. The institution offers a more traditional role of providing a safety net for service users. The discourse of recovery is prevalent among service providers only when asked directly; however, the actions and the sense given to recovery-oriented practice are evidenced through their discursive practices and their innovative and emerging practice. This ACT team seems to accomplish a hybrid type of recovery-oriented practice, in which some service users are externally evaluated as being on a "maintenance" track and others on a "recovery" track. Interventions and relationships are constructed in consequence of the outcome that is a priori determined for the service users. Both tracks include interventions that aspire to positively affect the service user's social environment (housing, social network, hygiene) and have a symbolic value associated with well-being, recognition, solidarity, and participation. Moreover, the two tracks in this recovery practice are embedded in the role that ACT plays as a proxy, unidirectional social network for most service users. The development of a proxy social network might be stimulated by the social skills training offered by ACT; it might also be reassuring and structuring for service users who require and desire that. However, there is a risk that it becomes a mechanism for "social contention" and limits effective development of sustainable and reciprocal social connections and social cohesion.

Despite the most progressive intentions of service providers, the recovery process and the construction of potential recoveryoriented interventions are negotiated not only for individual service users but also for groups of service users based on social workers' expectations of that group. Thus, there is a two-tiered approach to recovery for service users evaluated as having a capacity for rehabilitation, who are judged as having adequate insight, and another approach for services users that are judged to have low insight and therefore incapable of rehabilitation for the time being. For the former group, the type of interventions that are constructed can be categorized as "accompaniment" and for the latter group as "maintenance and safety net."

The two-tiered recovery approach represents a paradoxical institutional arrangement of accompaniment that remains highly individualized and relegates social inequalities to an unexamined background reality. Complex social problems, such as homelessness, are addressed more directly through the development of new organizational structures (PRISM) and approaches (street psychiatry), with the goals of providing solutions to individualized mental illness through medication and housing. Although this outreach is a first step to connecting and building a relationship with certain people experiencing distress, the framework of recovery is not a consideration or used as an orientating approach. Social interventions, both for those service users who are to be maintained in their stability and for those who are grouped into the category as having potential for transformation, are lacking a broader concern for social and collective concerns.

Service providers often cite the organizational constraints and the subsequent legal, medical, and administrative pressures as the most influential factor in the way interventions are conceived and constructed. These constraints and pressures lead to a focus on symptom reduction, harm and risk reduction, avoiding hospitalization, maintenance in the community through housing, and improved social connections/cohesion. The complex social difficulties and inequalities faced by the service users are often through interventions shaped by purpose rather than process and lead to recovery being reconceptualized into an individual responsibility. The context in which that individual must take responsibility for her recovery process, both socioeconomically and clinically, is not a predominant consideration. In other words, a service user, such as Liz, is experiencing feelings of hopelessness, marginalization, and also living with the effects of poverty and stigmatization, within the ACT context, she is able to establish therapeutic relationships that support and accompany her in finding housing, managing her substance use, and connecting with her family. However, Liz does not report being in a process of recovery because her existential goals are not being met. Moreover, the predominant recovery framework that is used is one in which Liz alone is responsible for her recovery, despite the current context in which her treatment, housing, and certain broader life choices are controlled by the very relationship she developed with the ACT team.

### The Importance of Interactions and Relationships

What I have explicated in this research is the appearance of different intervention strategies in ACT mental health practice. Service providers harness their organizational structures and their professional autonomy and knowledge to either a) access privileged moments and spaces for potentially transformative interventions or b) interact with service users through techniques that maintain spatial, temporal, and interpersonal stability. Despite the most progressive intentions of service providers, outcomes are negotiated not only for individual service users but also for groups of service users based on service providers' expectations of that group. That means that some groups of service users are considered to be on the "recovery track," and more complex interventions are envisioned, whereas other groups of service users, usually those with more complex problems, are on the "maintenance track," and more technical interventions are accomplished. The unequal outcomes by level of distress or suffering suggest that stigma or discrimination has become structured into the ACT program and the parent institution, through daily actions and interactions among actors in a mental health team, despite the goodwill and professionalism of many workers. Larger structural inequalities are not only constructed but also maintained within these interactions because service users and service providers are mobilized to accomplish tasks within the public space, outside of the institution, rather than to transform it.

Although service providers might feel empathy, compassion, and even affection for some service users, clear professional boundaries ensure that the development of a social network is unidirectional. Service providers, often social workers, find themselves in privileged spaces to develop relationships and promote dialogue with services users. These spaces can be in cab rides, walking down the street, moving, having a coffee. During these interactions, small acts of kindness, which service providers often dismiss as inconsequential, are interpreted as very meaningful and moving by service users. These small acts of kindness, which are not yet included in best practices literature, are developed when the dyadic relationship enters into a "dialogue" mode. It is perhaps, as suggested by Linda Bourgeois (35), a former service user, the first step to self-transformation and social transformation. These small gestures and acts of kindness are perhaps invisible actions and interactions that serve to reinforce a more flexible and participatory relationship, despite the fact that they are not easily categorized into a specific intervention approach. The quality of the interactions became apparent from how case managers paid attention, listened, and communicated while engaging in these shared activities. This study illustrates that although the structural aspects of SIM provided the context and opportunities for engagement, the quality of the interaction between the case managers and residents played a key role in engagement.

The particularity of the service providers that compose the ACT team is their continued hope, built through professional respect and through an awareness, if not necessarily always the capacity, to intervene in different ways than what is typically sanctioned in psychiatry and in our overarching results-based health and social service sector. The service provider who deals almost exclusively with the Individualised Placement Program explained that his passion for his work is based on his strong belief that it will provide hope for the service users and for himself as a professional.

## CONCLUSION

In short, in 2014, within this urban ACT team, the question of participative, service user-oriented practices in psychiatry is already being debated. This debate can be understood as situating this particular ACT team as not only a physical space where community mental health work is accomplished but also a social and political space wherein madness is woven into the fabric of the community and of society. This latter occupation unearths many of the constraints and questions regarding the relationship this psychiatric team has with the idea of madness and with the realities experienced by service users. The description of recovery and recovery-oriented perspective within this urban Montreal ACT team unveils an organizational structure that is opening the space for potentially creative and participative actions and interactions among actors—that is to say, interventions that seek out and sustain the participation of service users in their treatment and in their lives in the community. Perhaps paradoxically, this same structure is governed by traditional practices and neoliberal policies that maintain and support traditional professionalpatient relationships and cost-efficient treatments. Moreover, the position of this elite team within the psychiatric care structure might even legitimize the use of more coercive practices.