Psychiatric Rehabilitation Interventions Research Articles

Self-determination and self-efficacy as predictors of campus engagement among college students with serious mental illnesses.

Campus engagement, including participation in student organizations and groups, is important for both academic and health outcomes. Yet, college students with serious mental illnesses demonstrate lower levels of campus engagement compared to peers without mental illnesses. To inform psychiatric rehabilitation approaches that might enhance this outcome, the purpose of this study was to test an integrated model of self-determination and self-efficacy theories to predict campus engagement within this student population. Sixty-seven college students with serious mental illnesses completed measures assessing self-determination constructs (autonomy, competence, and relatedness), college self-efficacy, and campus engagement. Correlational and path analytic models examined relationships among these variables. Bivariate and multivariate analyses supported the interrelationships among the variables. Specifically, the theory-driven path model demonstrated that autonomy (but not competence or relatedness) was a significant predictor of college self-efficacy, which in turn was associated with campus engagement. Findings particularly highlight the importance of autonomy and self-efficacy for promoting campus engagement among college students with serious mental illnesses. As such, they may be relevant targets for psychiatric rehabilitation interventions, such as supported education, that are designed to enhance student success. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Relationship of Loneliness and Social Media Addiction with Gender Differences Among Undergraduate Students and Psychiatric Rehabilitation

This study aimed to uncover loneliness and its association with social media addiction among college students and suggest psychiatric rehabilitation interventions. The sample consisted of 50 male and 50 female college students. The scales used were the De Jong Gierveld Loneliness Scale and the Tutgun-Ünal and Deniz Social Media Addiction Scale, which consisted of 11 and 14 items, respectively. Statistical analysis was performed using SPSS (t-test). We examined three hypotheses. The first hypothesis showed a positive correlation between social media addiction and loneliness. The second hypothesis could not be confirmed. The second hypothesis stated that female students would score higher on the Social Media Addiction Scale than male students. The third hypothesis could also not be confirmed. The third hypothesis stated that female students would score higher on the De Jong Gierveld Loneliness Scale than male students. The statistical analysis showed that there is a positive and weak correlation between loneliness and social media addiction and that female students would not score high on the social media addiction and loneliness scales compared to male students. With these results, one of the hypotheses was confirmed and two of them were not supported. It was also suggested that psychiatric rehabilitation programs should be more student-centered, regardless of gender.

A qualitative exploration of stakeholders' perspectives on the experiences, challenges, and needs of persons with serious mental illness as they consider finding a partner or becoming parent.

While many persons with serious mental illness (SMI) consider intimate relationships and becoming parent as central parts of their lives deeply affecting wellbeing and recovery, others anticipate facing multiple challenges in these life domains. This qualitative study sought to explore the perspectives of persons with SMI and mental health providers (MHPs) with diverse backgrounds and practices on the experiences, challenges, needs and expectations of persons with SMI as they consider finding a partner or becoming parent. For this qualitative study, we conducted five focus groups between March and December 2020 for a total number of 22 participants (nine persons with SMI and thirteen MHPs) recruited from a center for psychiatric rehabilitation and a community mental health center in France. We used the inductive six-step process by Braun and Clarke for the thematic analysis. Participants reported some challenges related to intimate relationships, stigma/self-stigma, disclosure and decision-making about start a family. Their expectations included: (i) psychoeducation about decision-making about finding a partner and starting a family; (ii) support in making empowered decisions about finding a partner, starting a family or disclosure to a prospective partner or their child; (iii) peer-support interventions; (iv) enhancing coping strategies; (v) integrated service provision including home treatment interventions, training to recovery-oriented practices and access to dedicated resources for providers. In short, intimate relationships and desire to start a family for persons with SMI should be more considered in psychiatric rehabilitation and additional support and interventions should therefore be provided.

Vie affective, désir d’enfant et parentalité chez les personnes avec schizophrénie

While many people with schizophrenia consider intimate relationships and parenting as central parts of their lives deeply affecting well-being and recovery, others report multiple challenges in these domains (e.g. stigma, social isolation, low self-esteem, emotional dysregulation, sexual dysfunctions, separation/divorce and domestic violence, low treatment adherence, perinatal complications, parenting difficulties, alteration of the quality of early parent-infant interactions, interruptions to the parenting role and custody loss). However, these domains are often overlooked in routine clinical practice and in psychiatric rehabilitation. It is therefore crucial to discuss these topics more systematically (e.g., desire to become involved in a relationship or to become a parent, representation of self as a prospective partner, parent or future parent, sexual dysfunctions, family planning) to improve patients’ outcome, well-being, and quality of life. In addition to the existing service provision, this paper presents discussions of individual and group-based psychiatric rehabilitation interventions (e.g., informed decision-making and shared-risk taking, group cognitive behavior therapy, metacognitively oriented psychoeducation) that were developed to improve outcomes for patients, infants, and relatives.

Quels outils thérapeutiques en faveur du rétablissement dans la schizophrénie ?

Recovery is a multidimensional construct that encompasses both subjective (e.g. well-being, satisfaction with life, self-esteem) and objective outcomes (e.g. independent living, interpersonal and intimate relationships, work). Recovery can be defined either from a clinical perspective (i.e. clinical and functional remission) or from a consumer-focused one, as a self-broadening process aimed at living a meaningful life beyond mental illness. Recovery-oriented practices imply to create pro-recovery environment seeking to enhance hope, control, strengths, goal striving and self-management. Their implementation in mental health services has shown effectiveness in improving personal recovery. Psychiatric rehabilitation brings together a wide range of recovery-oriented interventions. A comprehensive clinical, functional and cognitive assessment is performed to establish the individual's strengths and weaknesses, autonomy, and occupational level. Therapeutic tools are selected based on the participant's personal life goals as part of an individualized psychiatric rehabilitation action plan. The action plan can include strengths-based case management, psychoeducation, improvements in physical and mental health, peer-support interventions, joint crisis plans, cognitive remediation (CR), cognitive behavior therapy (CBT), social skills training (SST), self-stigma reduction, making empowered decisions about disclosure, family support, recovery-oriented interventions from preconception to post-partum care and supported housing and supported employment. Psychiatric rehabilitation interventions improve patient's outcomes after one year of follow-up (i.e. symptom reduction, improvements in insight, treatment adherence and cognitive and psychosocial function). The access to psychiatric rehabilitation interventions remains however limited (1/3 of the participants with SSD included in the FondaMental Advanced Centers of Expertise for SSD) and should be further developed. Supported housing and supported employment improve the access to stable housing and sustained competitive employment. They have been associated to improved patient's outcomes and have shown to be cost-effective. Recovery-oriented interventions from preconception to post-partum care (reproductive health counseling, strength-based case management by a trained midwife, shared action plan, self-stigma reduction, cognitive remediation, gender-sensitive CBT and SST) could reduce the risk of psychiatric, obstetrical and neonatal complications. They could reduce the risks of parent-infant separation and custody loss and could prevent the development of psychosis in family high-risk children. These interventions should be further developed and evaluated. Recovery-oriented practices and psychiatric rehabilitation support recovery in people with SSD. The access to a comprehensive standardized evaluation and to a personalized recovery-oriented care including psychosocial treatment remains limited. Their implementation in mental health services figures among the priorities under the French decree on the territory national mental health plan for recovery-focused care.

Self-stigma in Serious Mental Illness: A Systematic Review of Frequency, Correlates, and Consequences.

Self-stigma is associated with poor clinical and functional outcomes in Serious Mental Illness (SMI). There has been no review of self-stigma frequency and correlates in different cultural and geographic areas and SMI. The objectives of the present study were: (1) to review the frequency, correlates, and consequences of self-stigma in individuals with SMI; (2) to compare self-stigma in different geographical areas and to review its potential association with cultural factors; (3) to evaluate the strengths and limitations of the current body of evidence to guide future research. A systematic electronic database search (PubMed, Web of Science, PsycINFO, Scopus, and Ovid SP Cumulative Index to Nursing and Allied Health Literature [CINAHL]) following PRISMA guidelines, was conducted on the frequency, correlates, and consequences of self-stigma in SMI. Out of 272 articles, 80 (29.4%) reported on the frequency of self-stigma (n = 25 458), 241 (88.6%) on cross-sectional correlates of self-stigma and 41 (15.0%) on the longitudinal correlates and consequences of self-stigma. On average, 31.3% of SMI patients reported high self-stigma. The highest frequency was in South-East Asia (39.7%) and the Middle East (39%). Sociodemographic and illness-related predictors yielded mixed results. Perceived and experienced stigma-including from mental health providers-predicted self-stigma, which supports the need to develop anti-stigma campaigns and recovery-oriented practices. Increased transition to psychosis and poor clinical and functional outcomes are both associated with self-stigma. Psychiatric rehabilitation and recovery-oriented early interventions could reduce self-stigma and should be better integrated into public policy.

Addressing Severe Mental Illness Rehabilitation in Colombia, Costa Rica, and Peru.

Many Latin American countries face the challenge of caring for a growing number of people with severe mental illnesses while promoting deinstitutionalization and community-based care. This article presents an overview of current policies that aim to reform the mental health care system and advance the employment of people with disabilities in Colombia, Costa Rica, and Peru. The authors conducted a thematic analysis by using public records and semistructured interviews with stakeholders. The authors found evidence of supported employment programs for vulnerable populations, including people with disabilities, but found that the programs did not include people with severe mental illnesses. Five relevant themes were found to hamper progress in psychiatric vocational rehabilitation services: rigid labor markets, insufficient advocacy, public subsidies that create conflicting incentives, lack of deinstitutionalized models, and lack of reimbursement for evidence-based psychiatric rehabilitation interventions. Policy reforms in these countries have promoted the use of medical interventions to treat people with severe mental illnesses but not the use of evidence-based rehabilitation programs to facilitate community integration and functional recovery. Because these countries have other supported employment programs for people with nonpsychiatric disabilities, they are well positioned to pilot individual placement and support to accelerate full community integration among individuals with severe mental illnesses.

The effect of rehabilitation combined with cognitive remediation on functioning in persons with severe mental illness: systematic review and meta-analysis.

Psychiatric rehabilitation (PR) can improve functioning in people with severe mental illness (SMI), but outcomes are still suboptimal. Cognitive impairments have severe implications for functioning and might reduce the effects of PR. It has been demonstrated that performance in cognitive tests can be improved by cognitive remediation (CR). However, there is no consistent evidence that CR as a stand-alone intervention leads to improvements in real-life functioning. The present study investigated whether a combination of PR and CR enhances the effect of a stand-alone PR or CR intervention on separate domains of functioning. A meta-analysis of randomized controlled trials of PR combined with CR in people with SMI was conducted, reporting on functioning outcomes. A multivariate meta-regression analysis was carried out to evaluate moderator effects. The meta-analysis included 23 studies with 1819 patients. Enhancing PR with CR had significant beneficial effects on vocational outcomes (e.g. employment rate: SMD = 0.41), and social skills (SMD = 0.24). No significant effects were found on relationships and outcomes of community functioning. Effects on vocational outcomes were moderated by years of education, intensity of the intervention, type of CR approach and integration of treatment goals for PR and CR. Type of PR was no significant moderator. Augmenting PR by adding cognitive training can improve vocational and social functioning in patients with SMI more than a stand-alone PR intervention. First indications exist that a synergetic mechanism also works the other way around, with beneficial effects of the combined intervention compared with a stand-alone CR intervention.

Rehabilitation Interventions to Promote Recovery from Schizophrenia: A Systematic Review.

Only one out of seven patients recovers after a first episode of psychosis despite psychiatric care. Rehabilitation interventions have been developed to improve functional outcomes and to promote recovery. We conducted a systematic review of the effectiveness of the main psychiatric rehabilitation interventions following a search of the electronic databases Pubmed, ScienceDirect, and Google Scholar using combinations of terms relating to cognitive remediation, psychoeducation, cognitive-behavioral therapies, and schizophrenia. Eighty articles relevant to the topic of interest were found. According to results, cognitive remediation has been found to be effective in reducing the impact of cognitive impairment, social skills in the learning a variety of skills and to a lesser extent in reducing negative symptoms, psychoeducation in improving compliance and reducing relapses, and cognitive therapy in reducing the intensity of or distress related to positive symptoms. All psychosocial rehabilitation interventions should be considered as evidence-based practices for schizophrenia and need to become a major part of the standard treatment of the disease.

Developing Family Options: Outcomes for mothers with severe mental illness at twelve months of participation

ABSTRACTFamily Options is a psychiatric rehabilitation intervention for parents with severe mental illness and their children who work with family coaches to set and achieve goals. The objective of this study is to compare changes in well-being, functioning, and supports and resources achieved from enrollment to 12 months by mothers participating in Family Options (N = 22) with changes from enrollment to 6 months. Mothers’ scores are compared on standardized measures of psychological distress, trauma symptom severity, mental and physical health status, social support, and the number of services needed but not received from enrollment to 6 months, and from enrollment to 12 months. Data were also obtained about help received and satisfaction with Family Options. Mothers achieved significant improvements in well-being at 12 months, as measured in terms of reductions in psychological distress and symptom severity scores. Significant improvements in social support and services received were reported at 6 month...

Quality of Life and Disability in Chinese People Living with Severe Mental Illness

Severe mental illness (SMI) drastically affects various areas of life. People living with SMI report general impairment in their functioning and poor quality of life. The aim of this study is to describe the prevalence of disability and quality of life in a cohort of Chinese people living with SMI. This was a cross-sectional study. Assessment scales included the World Health Organization (WHO) Disability Assessment Schedule-II, the WHO Quality of Life-BREF version, and the Positive and Negative Syndrome Scale. A total of 158 subjects participated in this study, who were mainly suffering from schizophrenia or related disorders (n = 73, 46.2 %). The prevalence of self-reported disability was as high as 69.6 % (n = 110). Subjects perceived higher levels of disability in the aspects of social participation, getting along with people and dealing with life activities. Overall, the total disability scores were significantly correlated with patients’ QOL and symptom severity (all P values <0.001). Older age was a significant risk factor for disability (OR 1.425, 95 % CI 1.016–1.999). Shorter duration of current hospitalization was a significant protecting factor for disability (OR 0.704, 95 % CI 0.508–0.974). This study found the prevalence of disability among Chinese people living with SMI was high. When the disability was more severe, it was significantly correlated with greater symptom severity and poorer quality of life. Statistically significant predictors of disability included older age and longer duration of current hospitalization. Future psychiatric rehabilitation intervention studies should be conducted to reduce the impact of disability on quality of life and other health outcomes for people living with SMI.

Evidence-based interventions in psychiatric rehabilitation: which ones should we prioritized and why?

This critical literature review describes current evidence-based psychiatric rehabilitation interventions. A brief description of recent meta-analyses and (or) literature reviews is presented for each targeted intervention, along with their revelance for psychiatric rehabilitation and their limits. The interventions presented include: family interventions, cognitive-behavioural therapy for psychosis, social skills training, cognitive remediation, integrated treatment for substance misuse and mental disorders, and supported employment programs. The psychiatric rehabilitation interventions presented in this article not only are based on empirical evidence but also offer clinical tools support the recovery of people with a severe mental illness.

Psychiatric rehabilitation and social inclusion of people with mental illness: a Portuguese experience and a critical analysis of current barriers

The delivery of psychiatric rehabilitation interventions has been recognised as fundamental to facilitate recovery of people with severe mental illness. Although Portugal has developed a plan to restructure mental health services between 2007 and 2016, multiple barriers are hindering its effective implementation. We aim to describe a Portuguese psychiatric rehabilitation institution and analyse barriers in the mental health paradigm change. With our experience, we intend to help countries that are planning or passing through a change of paradigm in mental health care to anticipate and avoid similar obstacles. Sources used were research literature, government policy documents and legislation, in loco experience and experiential knowledge. The case study was carried out using interactive (participant observation and non-structured interviews) and non-interactive techniques (document analysis, namely the target institution reports, projects and dossiers). Barriers found include not complying with the most re...

Cognitive Remediation and Psychosocial Rehabilitation for Individuals with Severe Mental Illness

Individuals with severe mental illnesses (SMI) such as schizophrenia are more likely to have impaired cognitive functioning in areas such as attention and concentration, psychomotor speed, memory, executive functions, and social cognition. These cognitive challenges are strongly associated with reduced psychosocial adjustment, such as the capacity for independent living, work or school, and social relationships, as well as the ability to benefit from rehabilitation programs targeted at improving outcome in these areas of adjustment. Cognitive remediation is the systematic use of methods aimed at improving cognitive functioning through the practice of cognitive exercises on either computer-based or paper and pencil tests, teaching more effective strategies for addressing cognitive challenges, and teaching coping or compensatory skills to reduce the effects of cognitive impairment on psychosocial functioning. For over 30 years, research has examined the feasibility and effects of cognitive remediation on cognitive functioning and psychosocial adjustment in people with SMI. Recent meta-analyses of controlled research have shown that cognitive remediation is associated with significant improvements in both cognitive functioning and psychosocial adjustment. However, these reviews of research have also found that the impact of cognitive remediation on psychosocial adjustment is contingent upon the provision of adjunctive or integrated psychiatric rehabilitation, such as supported employment or social skills training. That is, studies that have added or integrated cognitive remediation and psychiatric rehabilitation programs have been found to improve psychosocial functioning more than psychiatric rehabilitation alone, whereas studies that have added cognitive remediation to usual services have found little to no differences in psychosocial outcomes compared to usual services alone. This issue on cognitive remediation and psychiatric rehabilitation brings together six papers addressing topics critical to improving the long-term psychosocial functioning of people with SMI. Four of these papers provide pertinent reviews of research that point the field in important new directions, and two papers are original research contributions. While the research suggests that combining cognitive remediation with psychiatric rehabilitation is more effective at improving psychosocial outcomes, very little is known about how such programs should be combined. The review by R. Penades and colleagues addresses this question by providing a framework and hierarchical flowchart for integrating cognitive remediation with other evidence-based psychosocial interventions. D. L. Roberts and D. L. Velligan review relevant research suggesting that programs specifically developed for and targeting social cognition (e.g., emotion recognition, ability to infer other's mental states) may be more effective and efficient than broad-based cognitive remediation programs. This review has important implications for developing or refining cognitive remediation and psychiatric rehabilitation interventions in order to maximize their cost effectiveness. N. Contreras and colleagues provide a theoretical review of strategies for improving workforce participation in people with a SMI, with a particular focus on the Australian context. The review highlights the Individual Placement and Support (IPS) model of vocational rehabilitation, the most empirically validated program for improving employment outcomes in people with SMI, which has recently been combined with cognitive remediation in the USA. The authors suggest that Australia may be in a prime position to implement such combined interventions. N. Boycott and colleagues also focused in their review on the IPS model, with a particular aim at evaluating the effects of supplementary interventions on work outcomes, including cognitive remediation. While prior research has evaluated the impact of adding cognitive remediation to vocational rehabilitation for people with SMI, scant attention has been paid to integrating cognitive remediation with supported education for this population. The paper by S. A. Kidd and colleagues addresses this lacuna by providing encouraging pilot data from such an integrated program, supporting both the feasibility of integrating cognitive remediation with supported education, and suggesting benefits in education-related outcomes. Finally, the research paper by M. N. Levaux and colleagues provides a useful case illustration of how cognitive remediation can be individually integrated and tailored into helping a person accomplish everyday life tasks. We believe that the papers compiled in this issue make an important contribution to the cognitive remediation field by providing useful syntheses of the research literature, suggesting new directions for research and clinical implementation, and presenting new data on promising programs and approaches to integrate cognitive remediation and psychiatric rehabilitation into people's daily lives. Susan R. McGurk Shaun M. Eack Matthew Kurtz Kim T. Mueser

TREE: a Dutch multi-centre (cluster) randomized trial of a recovery program of/for persons with severe mental illness

Background/Objectives: There is growing evidence for the effectiveness of several psychiatric rehabilitation interventions in helping people with severe mental illness building a meaningful life in the community. There is no evidence to determine whether a user developed and user run recovery program (TREE) supports recovery processes and reduces psychiatric symptoms in the participating group.

Exploring Social Participation of People with Cluster B Personality Disorders

This study aimed to describe the impact of living with a cluster B personality disorder in an acute phase on social participation. A descriptive cross-sectional design was used. During their first week in a day hospital or inpatient admission, 31 participants completed the Assessment of Life Habits, examining the quality of social participation in 77 daily activities and social roles (life habits). The participants presented significantly more difficulties and dissatisfaction in realizing social roles than daily activities. Areas of life perceived to be the most problematic to accomplish were leisure, school, and work. Interpersonal relationships and fitness were the least satisfying. Personal care was the least disrupted and most satisfying life habit. Life habits that could be prioritized in psychiatric rehabilitation interventions with people with cluster B personality disorders included leisure activities, work and school, fitness, and interpersonal relationships.

Randomized trial of social rehabilitation and integrated health care for older people with severe mental illness.

The Helping Older People Experience Success (HOPES) program was developed to improve psychosocial functioning and reduce long-term medical burden in older people with severe mental illness (SMI) living in the community. HOPES includes 1 year of intensive skills training and health management, followed by a 1-year maintenance phase. To evaluate effects of HOPES on social skills and psychosocial functioning, we conducted a randomized controlled trial with 183 older adults with SMI (58% schizophrenia spectrum) age 50 and older at 3 sites who were assigned to HOPES or treatment as usual with blinded follow-up assessments at baseline and 1- and 2-year follow-up. Retention in the HOPES program was high (80%). Intent-to-treat analyses showed significant improvements for older adults assigned to HOPES compared to treatment as usual in performance measures of social skill, psychosocial and community functioning, negative symptoms, and self-efficacy, with effect sizes in the moderate (.37-.63) range. Exploratory analyses indicated that men improved more than women in the HOPES program, whereas benefit from the program was not related to psychiatric diagnosis, age, or baseline levels of cognitive functioning, psychosocial functioning, or social skill. The results support the feasibility of engaging older adults with SMI in the HOPES program, an intensive psychiatric rehabilitation intervention that incorporates skills training and medical case management, and improves psychosocial functioning in this population. Further research is needed to better understand gender differences in benefit from the HOPES program.

Psychiatric rehabilitation interventions: A review

Psychiatric rehabilitation has become accepted by the mental health field as a legitimate field of study and practice. Over the last several decades various psychiatric rehabilitation programme models and procedures have been developed, evaluated and disseminated. At the same time the process of psychiatric rehabilitation has been specified and its underlying values and practitioner technology articulated. This review describes the psychiatric rehabilitation process and in so doing differentiates psychosocial interventions that can be classified as psychiatric rehabilitation interventions from other psychosocial interventions. Furthermore, the major psychiatric rehabilitation interventions are examined within a framework of the psychiatric rehabilitation process with a review of their evidence. The review concludes that psychiatric rehabilitation interventions are currently a mixture of evidence-based practices, promising practices and emerging methods that can be effectively tied together using the psychiatric rehabilitation process framework of helping individuals with serious mental illnesses choose, get and keep valued roles, and together with complementary treatment orientated psychosocial interventions, provide a broad strategy for facilitating recovery.

Preference in random assignment: implications for the interpretation of randomized trials.

Random assignment to a preferred experimental condition can increase service engagement and enhance outcomes, while assignment to a less-preferred condition can discourage service receipt and limit outcome attainment. We examined randomized trials for one prominent psychiatric rehabilitation intervention, supported employment, to gauge how often assignment preference might have complicated the interpretation of findings. Condition descriptions, and greater early attrition from services-as-usual comparison conditions, suggest that many study enrollees favored assignment to new rapid-job-placement supported employment, but no study took this possibility into account. Reviews of trials in other service fields are needed to determine whether this design problem is widespread.

A one year follow-up of illness management and recovery: Participants' accounts of its impact and uniqueness.

Illness Management and Recovery (IMR) is a standardized curriculum-based intervention to help people with serious mental illnesses acquire knowledge and skills to manage their illnesses effectively and achieve personal recovery goals. Recent evaluations of IMR have shown promising results with regard to feasibility and effectiveness. The aim of the present study was to investigate and describe (1) whether participants perceived IMR as effective a year after completion, (2) if so, in what domains did they experience the IMR program to be beneficial, and, (3) in what ways did the IMR program differ from prior rehabilitation interventions they had experienced. 36 people with serious mental illnesses completed the Narrative Evaluation of Intervention Interview (NEII), a year after completing IMR. Qualitative analysis of the interviews involved two judges independently identifying themes. Inter-rater reliability ranged from .63 to 1.00. Participants reported high levels of perceived helpfulness. Three domains of improvement attributed to IMR included cognition, coping, and social support. With regard to the uniqueness of the IMR intervention, five categories emerged: Learning new information, social support, coping and self management, program structure, and message of hope. The positive impact of IMR reported in previous studies lasts as long as a year. Domains of reported improvement partially overlap with outcomes reported in previous studies. IMR is perceived to differ in several ways from other psychiatric rehabilitation interventions, both in technique as well as in message.