University of Groningen

Facilitating recovery in people with psychosis

Vogel, Sjoerd

DOI:
10.33612/diss.217103261

IMPORTANT NOTE: You are advised to consult the publisher's version (publisher's PDF) if you wish to cite from
it. Please check the document version below.

Document Version
Publisher's PDF, also known as Version of record

Publication date:
2022

Link to publication in University of Groningen/UMCG research database

Citation for published version (APA):

Vogel, S. (2022). Facilitating recovery in people with psychosis. University of Groningen.
https://doi.org/10.33612/diss.217103261

Copyright
Other than for strictly personal use, it is not permitted to download or to forward/distribute the text or part of it without the consent of the
author(s) and/or copyright holder(s), unless the work is under an open content license (like Creative Commons).

The publication may also be distributed here under the terms of Article 25fa of the Dutch Copyright Act, indicated by the “Taverne” license.
More information can be found on the University of Groningen website: https://www.rug.nl/library/open-access/self-archiving-pure/taverne-
amendment.

Take-down policy
If you believe that this document breaches copyright please contact us providing details, and we will remove access to the work immediately
and investigate your claim.

Downloaded from the University of Groningen/UMCG research database (Pure): http://www.rug.nl/research/portal. For technical reasons the
number of authors shown on this cover page is limited to 10 maximum.

Download date: 31-10-2022

Chapter 2
Peer support and skills training
through an eating club for people
with psychotic disorders: A
feasibility study

Jelle Sjoerd Vogel

Marte Swart
Mike Slade
Jojanneke Bruins
Mark van der Gaag
Stynke Castelein

Published in Journal of Behavior Therapy and Experimental Psychiatry (2019)

Vogel, J. S., Swart, M., Slade, M., Bruins, J., van der Gaag, M., & Castelein, S. (2019). Peer
support and skills training through an eating club for people with psychotic disorders: A
feasibility study. Journal of behavior therapy and experimental psychiatry, 64, 80–86.
 Abstract

Objective
The HospitalitY (HY) intervention is a novel recovery oriented intervention for people
with psychotic disorders in which peer support and home-based skill training are
combined in an eating club. A feasibility study was conducted to inform a subsequent
randomised trial.

Methods
This study evaluated three eating clubs consisting of nine participants and three nurses.
Semi-structured interviews and pre- and post-intervention measures (18 weeks) of
personal recovery, quality of life and functioning were used to evaluate the intervention.
Participants received individual skills training, guided by self-identified goals, while
organising a dinner at their home. During each dinner, participants engaged in peer
support, led by a nurse.

Results
In personal interviews participants reported positive effects on social support,
loneliness, and self-esteem. Nurses reported that participants became more
independent during the intervention. Participants were satisfied with the HY-
intervention (attendance rate = 93%). All were able to organise a dinner for their peers
with practical support from a nurse. Pre- and post -intervention measures did not show
important improvements.

Limitations
Outcome measures were not sensitive to change, likely due to a short intervention
period (5 months) and a limited number of participants (N=9). Using Goal Attainment
Scaling to evaluate personal goals turned out to be unfeasible.

Conclusions
The HY-intervention is feasible for participants with psychotic disorders. This study
refined intervention and research design for the upcoming multicentre randomised
controlled trial. We expect that the Experience Sampling Method will be more sensitive
to changes in recovery outcomes than regular pre- post intervention measures.

22
Introduction

People with a psychotic disorder, such as schizophrenia, often have to cope with severe
limitations in functioning related to their illness [1,2]. These can lead to a loss of self-
management [3] and social and community functioning [4] and in turn to loneliness,
social isolation, and internalised stigma [2,5]. During the last decades, personal recovery
has gained more attention in the mental health field [6,7]. Personal recovery focuses on
living a satisfying, hopeful and contributing life in spite of illness-related limitations [8]. A
systematic review identified five processes involved in personal recovery:
Connectedness, Hope and optimism, Identity, Meaning in life and Empowerment
(CHIME) [9]. Many of these processes emerge in relationships with others. This
conceptual framework therefore highlights the need for interventions that target
loneliness and social isolation as well as social and community skills, which facilitate
social contact.
Improving skills for people with psychotic disorders has been an important
subject of research in mental health during the last decades. Skills training in a clinical
setting has a limited generalisation to real life situations [10]. Home-based interventions
are expected to be more effective, because skills are learned in the same context as
needed in daily life [11,12] Previous studies indeed showed that home-based
interventions in schizophrenia led to more improvement in social and community
functioning compared to traditional clinic-based interventions [13]. Severe
neuropsychological impairments in episodic memory and executive control processes
are present in schizophrenia [14]. Evidence shows that these cognitive deficits result in
poor functioning [15]. Recent research shows that compensating interventions for
cognitive deficits lead to improvements in functioning [16].
Peer contact and support groups are widely used interventions to foster social
connectedness as stated in the CHIME framework [17]. This is confirmed by research
demonstrating the effect of peer support on social networks and social support [18,19].
Peer support is based on mutual recognition through similar experiences. Therefore,
peers can offer authentic empathy and validation [20]. Also, Identity forming is one of
the pathways in which social connectedness is positively influenced by peer support
[21]. Furthermore, peer support effectively improves recovery, empowerment and
feelings of hope [22,23]. Barriers in peer contact are deficits in social cognitive domains,
known to be present in people with schizophrenia [24]. A more proximal mechanism is
found in defeatist believes that contribute to the avoidance of social activities [25].
Therefore, in group activities a safe atmosphere should be facilitated for peers to engage
in social contact.
In light of promising results in both home-based skills training and peer
support, we developed a synergistic approach that is expected to improve patients’
functional and personal recovery. This paper presents a feasibility study of the
HospitalitY intervention: a recovery-oriented intervention combining peer-support and
home-based skills training for people with psychotic disorders. This creates an integrated
approach that combines functional and personal recovery domains [26,27]. The
intervention is structured around an eating club. Having dinner together creates a peer
support setting and organising a dinner offers many naturally occurring opportunities to
work on social and community living skills in the participant’s personal environment. An

23
 appointed nurse provides a safe atmosphere by being present [28] and providing
encouragement and positive reinforcement [10], as a prevention to defeatist beliefs [25].
Furthermore, based on social learning principles, motivation to work on personal goals is
leveraged by participating in a meaningful group activity [29,30].
We developed a personal recovery focused intervention with input from a
service user. Subsequently, we conducted a feasibility study to evaluate the suitability of
this intervention for people with psychotic disorders and nurses. Furthermore, this study
aimed to calculate a sample size for our primary outcome and to explore several
potential outcome measures for a subsequent randomised trial.

24
Materials and Methods

Intervention
The intervention comprises three phases. In the first phase, participants have an
individual meeting with the allocated nurse for an introduction, preferably at the
participants’ home. During this meeting, the intervention is explained and goals and
wishes of the participant are explored in a semi-structured interview (e.g., What are your
wishes and goals for the eating club?).
In the second phase, the peer group members (n=3) and the nurse meet at a
hospital or community centre to get acquainted with each other. In this meeting,
participants make agreements about the planning of the biweekly dinners and other
practicalities (e.g., dates, diets, finances) and brainstorm about topics that can be
discussed during the future peer group sessions (i.e., dinners). The eating club is
expected to be self-supporting where possible. Therefore, financial costs of the dinners
are shared between the members and participants learn how to organise such dinners
within their own financial situation.
The third phase is a period of 18 weeks in which participants take turns in
organising a total of nine dinners (three per participant) at home and with support from
a nurse. Participants receive individual home-based skills training while organising a
dinner for their peers and the nurse three different times. By hosting a dinner,
participants will work on several skills such as planning, cooking and social skills to
increase their functional recovery. The skills training is focused on the self-identified
goals and is counselled by the nurse. The frequency and mode (e.g., in person or by
telephone) of counselling varies per participant depending on the patients’ needs and
progress throughout the intervention period. Skills training consist of practical support
in organising a dinner for peers [17] and techniques to adapt the environment to the
participants needs. Adaptation techniques are utilized to compensate for cognitive
deficits, known to be present in people with psychotic disorders [31]. Applying these
simple and straightforward adaptations can increase functional independence in
participants who experience cognitive difficulties. Examples of adaptation techniques
are: structuring kitchen cabinets with the use of labels or make use of calendars.
Furthermore, standardised nursing interventions were used as described in the Nursing
Interventions Classification (NIC) [32], such as behaviour modification, social skills, self-
esteem enhancement or self-responsibility facilitation.
During dinner, the nurse offers support according to the Guided Peer Support
Groups (GPSG) method [19] (i.e., offering structure without interfering in conversations
between participants). Peer support is structured around a two-course dinner. During
the main course, participants exchange positive experiences they had during the past
two weeks. During the second course an illness-related topic of conversation is chosen
and afterwards discussed in a twenty-minute session. An outline of the intervention is
presented in Table 1.

25
 Table1. Outline of the HospitalitYProject
Phase Description Time Goal
Recruitment of The nurse and participant meet for 30 minutes per Determining the
participants the first time, preferably at the participant. suitability of the
participantʼs home. participant for this
The intervention is explained. Goals intervention and
and wishes of the participant are inclusion in the
explored with a semi structured study.
interview.
Start-up The peer group, including the 60 minutes per Participants will
meeting appointed nurse, will meet at a session. meet to get to know
hospital or community center. each other.
The participants will make
agreements about practicalities.
The participants brainstorm about
topics that can be discussed during
the peer group sessions.

Intervention Home-based skill training: In turn, Varying from 30 Facilitating

participants will organise dinners at to 120 minutes. participants in
obtaining functional
home for their peers and the nurse.
recovery.
Peer support: During dinner, peer 120 minutes per Fostering social
support is carried out using the session. contact and peer
Guided Peer Support Groups support.
methodology for nurses.

Measurements
The intervention was evaluated on five different aspects. First, attendance of participants
to the dinners was registered by the mean number of attended dinners during the
intervention period for each participant (maximum is 9). Second, experiences from
participants and nurses were collected with semi-structured interviews conducted by
the first author and research assistants. Participants were prompted to talk about their
thoughts regarding the skills training, goals, peer support, nurse support, and organising
the dinners. Interviews were interpreted with an inductive strategy: repeatedly reported
themes where clustered and matching opinions were summed. Third, goal attainment of
participants was measured with the Goal Attainment Scaling (GAS) method [33]. This
method enables the achievement of personal SMART formulated goals (Specific,
Measurable, Achievable, Relevant, Time bounded) to be used as an intervention
outcome. The nurse and participant determine attainment on a 5-point scale (1= much
less than expected outcome and 5= much more than expected outcome). Goals were
considered achieved with scores ≥3. Fourth, treatment fidelity of the nurses was
assessed with an open interview and a protocol adherence questionnaire (27 items),
which was completed by the nurse after each meeting of the eating club. The

26
questionnaire comprised four topics: self-identified goals (4 items), organising a dinner
(6 items), peer support (9 items) and group process (8 items). Items were scored on a 5-
point Likert scale (1= completely disagree and 5= completely agree), where higher
scores equal more adherence. Protocol adherence was analysed by calculating the mean
scores on the protocol adherence questionnaire, where a mean score of ≥88 (range
27-135) was considered sufficient. Fifth, standardised measures were used to determine
their sensitivity and feasibility for this intervention. We calculated a Reliable Change
Index (RCI) for each measure if the Cronbach’s alpha for the questionnaire was available
[34]. The outcome of the RCI shows the minimal change needed for a reliable
improvement. Measurements of personal recovery, quality of life, functional recovery
and psychopathology were administered within a range of one to three weeks pre- and
post-intervention. All measures were self-rated, except for the Personal and Social
Performance (PSP) scale [35]. Questionnaires were analysed on responsiveness by
comparing pre- and post-intervention scores. Missing values were imputed by using the
means of the total score or by Last Observation Carried Forward when questionnaires
were smaller than 20 items. The results of a questionnaire were not included in the
analysis if >50% of the values on a measure were missing.

Personal recovery domains were measured with the:

• Recovery Assessment Scale (RAS) (range: 41-205, Chronbachs’ α=0.76 - 0.97. Test-
retest reliability: r=0.65 - 0.88 [36]. Higher scores indicate more personal recovery.

• Netherlands Empowerment List (NEL) (range: 40-200, Chronbachs’ α= 0.94, test-

retest reliability= 0.79) [37]. Higher scores indicate more personal recovery.

• Lubben Social Network Scale, six item version (LSNS-6) (range: 0-30, Chronbachs’ α=
0.83) [38]. Higher scores indicate a greater social network.

• Personal Network Questionnaire (PNQ) (range: 0-18). The PNQ was developed in a
previous study [19] and measures the satisfaction of the amount of contact the
patient has with important “others” in his/her life. Psychometric properties are not
available. Lower scores indicate a higher satisfaction.

Quality of Life (QoL) was measured with the:

• Manchester Short Assessment of Quality of Life (ManSA) (range: 0-72, Chronbachs’

α= 0.74) [39]. Higher scores indicate more quality of life.

• Short Form Health Survey 12 item version (SF-12) (range: 0-100, Chronbachs’ α= 0.69
– 0.70 test-retest reliability= 0.60 - 0.71 [40]. Higher scores indicate more quality of
life.

27
 Functional recovery was measured with the:

• Personal and Social Performance scale (PSP) (range: 0-100, intraclass correlation
coefficient = 0.98) [35]. Higher scores indicate a better personal and social
functioning.

• Daily Task List (DTL). The DTL measures basic functional living skills and was
developed specifically for this project, broadly based on the following subscales of
the Independent Living Skills Survey (ILSS) [41]: Appearance and Clothing, Personal
Hygiene, Care of Personal Possessions and Food Preparation/Storage. The DTL was
developed for this intervention as standard questionnaires were not deemed
suitable for this intervention. Psychometric properties are not available. Higher
scores indicate better functioning.

Psychopathology with the:

• Community Assessment of Psychic Experiences (CAPE), which measures frequency

and distress of symptoms on three dimensions: positive (range: 40-160, Chronbachs’
α= 0.84), negative (Chronbachs’ α= 0.81) and depressive (Chronbachs’ α= 0.76) [42].
The CAPE is an accessible questionnaire that is used as a self-report questionnaire
for this population in previous research [19]. This psychopathology measure was
included to evaluate adverse effects. Higher scores indicate a higher frequency and
more distress of symptoms.

Procedures
A blueprint of the HospitalitY intervention was developed based on scientific literature
and the expert knowledge of a panel, consisting of a person with lived experience, a
researcher and several mental health care professionals. The first author developed a
detailed treatment protocol. Study procedures were in accordance with local and
international ethical standards and the Declaration of Helsinki [43], as confirmed by the
review board of the University Medical Centre Groningen (UMCG), The Netherlands (file
number: 2014.479).
The intervention was delivered by mental health nurses or health care workers
with similar professional profiles (e.g., social workers) based on the best fit with their job
descriptions and on comparable interventions in previous research [19]. Nurses received
a manual, a full day of training and supervision from a nurse consultant specialised in
psychotic disorders and in facilitating peer support groups for this group. During the
project, a two-hour interprofessional coaching session was organised to reinforce the
methodology. Participants who were interested in the HospitalitY intervention were
recruited from a Flexible Assertive Community Team (F-ACT) of Lentis Psychiatric
Institute between April 2014 and March 2015. Follow-up ended in September 2015.
Participants were enrolled in an eating club, in order of entry to study. All participants
provided written informed consent. Participants had a DSM IV chart diagnosis of
schizophrenia, schizoaffective disorder, or psychotic mood disorder [44]. Inclusion
criteria were: 18 - 65 years of age and sufficient fluency in Dutch language. The exclusion
criteria were: severe psychotic symptoms or group disturbing behaviour, substance
dependence on alcohol or other drugs; frequent existing participation in dinners with
peers and personal contribution (i.e., cooking).

28
Results

Sample
Nine participants were included in the study. The median age was 38 (range: 27-62).
Gender was evenly distributed (n=5 male, n=4 female). Participants received income
from welfare assistance (n=8) or employment (n=1). One participant received higher
education and the other eight received secondary education. Participants were single
(n=7), divorced (n=1) or had a partner (n=1) and were diagnosed with schizophrenia
(n=7), bipolar disorder (n=1) or schizoaffective disorder (n=1).

Attendance
The mean attendance for all participants during the nine dinners was 93%. Per eating
club, the full attendance rate was seven out of nine dinners (range: 6-8). Eight
participants completed the project and one dropped out before the final session due to
an exacerbation of symptoms. No clear relationship between the project and the
exacerbation of symptoms was found after interviewing the participant and case
manager.

Interview reports
Overall, seven out of nine participants were interviewed. Participants described their
participation in the HospitalitY intervention as a positive experience. They either
expressed a desire to continue (n=3) or initiated a new dinner group with members from
other eating clubs (n=3). They reported being nervous to invite people into their home
at first and that the HospitalitY intervention was demanding. However, in retrospect they
were pleased they joined the project and would recommend it to their peers. All
participants were able to properly organise a dinner according to nurses’ and
participants’ judgements. Participants reported that three participants per group is
comfortable in terms of interpersonal contact as well as practical in modest housing
space and preparing a dinner.
Peer support: approximately half of the participants reported that the twenty-
minute peer support sessions gave them insight in their illness or a feeling of freedom to
share psychiatry-related experiences they could not share with others (n=4). Others had
mixed views: some reported this was a forced way of talking about difficult matters and
not really worthwhile, because having social contact and being in a group was more
important (n=4). Most participants reported they valued social contact during the
dinners, felt less lonely and experienced a sense of community participation (n=6).
Skills: participants enjoyed preparing dinner for their peers (n=4), which
increased their self-confidence despite concerns prior to the start of the project.
Increased insight in functioning and social contexts (e.g., how one is viewed by others)
was also reported (n=6). Participants stipulated that the group was used as a mirror to
gain insight in how to deal with life in general and living with a psychiatric diagnosis.
Furthermore, participants talked about how they gained insight in their personal
tendencies through the group process and mediation from the nurse. Nurses evaluated
the process of the organisation and the course of the dinner with the individual
participant after the other participants had left.
Nurse support: nurse-support was perceived as useful and gave participants a

29
 sense of security (n=5). Some participants stated they would not have partaken the
project without the nurse. Important features of the nurse were described as being
present, creating a sense of safety and structuring the sessions.
Reports from nurses: nurses highlighted that they experienced a contrast
between the routine care, that is problem-focused, and the recovery oriented care
offered during the HospitalitY intervention. They emphasised that it was energising to
focus on strengths rather than deficits and that working in a group increased
participants’ motivation to work on skills. Participation was initially demanding for
nurses as the counselling was time-consuming. However, participants became more
independent, which led to less involvement from the nurse during the preparation of
the dinner.

Goal attainment
Participants formulated a mean of 2.5 goals per person (range: 1-4). Most self-identified
goals focused on gaining skills in organising and preparing group meals (n=9) and
varied from cooking and hosting a group of people to cooking healthy, dealing with
budget or grocery shopping. Other goals focused on having more social contact with
others (n=6), social skills or gaining self-confidence in social situations (n=5) and having
peer contact specifically about diagnosis-related subjects (n=3). The mean number of
achieved goals was 1.9 (range: 1-3) (NB. this could not be rigorously measured using GAS
as explained in the strengths and limitation section of the discussion).

Treatment fidelity
Completion scores on the protocol adherence questionnaire were less than 20%.
Therefore, only the personal interviews could be used to assess treatment fidelity of the
nurse. In personal interviews, nurses reported they rarely used environmental adaption
techniques, which were the primary techniques as instructed in the manual and training.
Instead, nurses relied more on nursing interventions as described in the NIC [32]. The NIC
approach was applicable on a wide range of the participants’ goals. Exercising the GPSG
methodology was found difficult at the start, because nurses as well as participants
needed a few sessions to get used to the role of the nurse. Nurses reported that using
GAS to form and evaluate goals turned out to be unfeasible. Although participants did
formulate goals, these goals did not adhere to the SMART standards. To use GAS,
defining SMART formulated goals is paramount.

Measurements
The measured constructs were congruent with the topics that participants and nurses
described as important in the semi structured interviews. All participants were able to
complete the questionnaires and the interview (PSP). Pre-and post-measures did not
show to be sensitive for change during the intervention period of 18 weeks. Personal
recovery and quality of life measures showed small contradicting changes (i.e., both
positive and negative changes were found). On personal recovery measures mean scores
improved on the NEL and the SNA, but not on the RAS and LSNS. On QoL measures, the
mean score of both SF12 components improved whereas the mean score of the ManSA
decreased. Measures of functioning showed small positive changes (PSP, DTL). The CAPE
showed a slight decrease in symptoms on all dimensions. The RCI of the questionnaires

30
showed that participants did not improve on most measures. On both the SF12 physical
component and the CAPE-negative three participants improved. On the NEL and CAPE-
positive one participant improved. The mean scores of the measurements and the RCI
are reported in table 2.

Table 2. Outcome measurement of HospitalitY intervention (N=9): pre and

post treatment at 18 weeks
Pre-treatment: Post-treatment: RCI (N)
Mean (SD) Mean (SD)
Recovery Assessment Scale (RAS) total score* 159.0 ±23.4 154.4 ±26.8 0
Netherlands Empowerment List (NEL) total score* 154.6 ±21.7 155.6 ±22.2 1
Personal Network Questionnaire(PNQ)# 4.3 ±4.2 3.8 ±3.2 N/A
*
Lubben Social Network Scale (LSNS) 12.3 ±5.5 11.4 ±4.5 0
Manchester Short Assessmentof Quality of Life 44.6 ±7.3 40.9 ±13.2 0
(ManSA)*
Short Form Health Survey -12(SF12) physical 49.1 ±11.9 51.1 ±10.7 3
component*
Short Form Health Survey -12(SF12) mental 42.4 ±7.7 44.8 ±11.4 0
component*
Personal and Social Performance (PSP) scale total 64.4 ±9.4 65.7 ±15.9 N/A
score*
Daily Task List (DTL)* 41.8 ±8.4 42.0 ±7.2 N/A
Community Assessment of Psychic Experiences 50.8 ±10.6 48.3 ±8.0 1
(CAPE)– Positive dimension#
Community Assessment of Psychic Experiences 49.7 ±9.9 48.1 ±10.9 3
(CAPE)– Negative dimension#
Community Assessment of Psychic Experiences 29.2 ±6.7 28.2 ±8.5 0
(CAPE)– depressive dimension#
* higher scores indicate better outcome; #higher scores indicate worse outcome; RCI= Reliable
Change Index (N= number of participants with a reliable improvement).

31
 Discussion

In this study we examined the feasibility of the HospitalitY intervention, an eating club
combining peer support with skills training for people with psychotic disorders. The
intervention seemed to be feasible according to participants and nurses: Participants
showed high motivation to work on personal goals; all participants were able to organise
a dinner for their peers with practical support from a nurse; high satisfaction rates were
found; and positive effects were reported on social support, loneliness, and self-esteem.
The results on measurements showed small contradicting changes. In addition, the
number of participants that reliably improved on measures is low. Therefore, outcome
measures did not show responsiveness to this short intervention period.

Strengths
This is the first study that evaluated peer support and home-based skills training
combined in an eating club. The strength of this intervention is providing psychosocial
interventions in the context of a meaningful activity. The HospitalitY intervention was
well received by participants and nurses and the attendance rate was high. Participants
showed high motivation to work on personal goals and the vast majority of personal
goals were achieved. Personal goals in a meaningful and social context might explain
this high motivation [30,45]. The presence of a nurse was pivotal for participants to feel
safe in exposing themselves to socially challenging interventions, consistent with
previous research [46] (Castelein et al., 2008). Furthermore, no adverse effects on
psychopathology as assessed with the CAPE, resulted from this intervention. Therefore,
this novel nurse led intervention was considered to be suitable for people with psychotic
disorders.

Limitations
The limited sample size (N=9) impedes final conclusions on the sensitivity for change of
the questionnaires used for this intervention. However, patients reported to have
experienced positive changes in social support, loneliness and self-esteem in personal
interviews. The discrepancy of the measurements not reflecting the reported
improvements in recovery outcomes and skills may be due to the short intervention
period (9 sessions in 18 weeks) and the limited sample size (N=9). Positive effects of
group-interventions might require more time to develop, as previous research on peer
support groups showed that high attenders to sessions (≥ 9) improved significantly on
psychosocial outcomes compared to low attenders (<9) [46]. Furthermore, our primary
interest personal recovery, is a highly individual and subjective process [4,47,48], which
is broadly defined construct and therefore not easily measured. This is reflected in the
divergent subjects that participants brought up in their report. While some participants
put a lot emphasis on social support, others experienced a change in loneliness or
empowerment. Therefore, measuring personal recovery with standard questionnaires
was found to be insufficient for this intervention. Similarly, no golden standard is
available for measuring functioning, validity and reliability of functioning measures are
highly depending on context [4]. We therefore developed the DTL based on the ILSS. The
DTL, however, demonstrated insufficient sensitivity for the HospitalitY intervention in
this feasibility study. Furthermore, our design (pre-post measurement) did not allow us

32
to anticipate on participants’ willingness to be randomised for the upcoming RCT.
A rigorous evaluation of the methodology was not possible due to the low
number of treatment adherence forms that were completed by nurses. However,
personal interviews with nurses did result in specific recommendations (for example:
goal formulation and skills training) to improve the HospitalitY intervention.
With regard to intervention implementation, we found that defining SMART
goals, as part of the GAS method, is a time-consuming activity that is demanding for
participants with cognitive problems, similar to a previous study [49]. Therefore, using
GAS was found to be unfeasible. Furthermore, adapting patients’ environment to
compensate for cognitive deficits was not an appropriate approach in skill training. We
found this approach was too narrow for the wide variety of participants’ goals.

Modifications
Based on this feasibility study, four aspects were modified with regard to the
intervention as well as to the measurements. First, the intervention will be extended
from 18 to 30 weeks (15 dinners). This will allow for several proposed processes (e.g.,
group forming and skills competence), which are expected to lead to more momentum
in gaining social contact, empowerment, community functioning and a decline in self-
stigma. Second, less emphasis will be put on adapting patients’ environment to
cognitive deficits during the skills training. Instead, nurses are instructed to use a broad
range of interventions as described in the NIC [32]. Additionally, nurses are instructed to
look for learning opportunities, encourage participants to use their skills, and to
reinforce skills when used [50]. Third, GAS will not be used as a method for measuring
individual progression on goals, so that participants’ goals do not need to comply with
the SMART approach. However, individual goal formulation will be used to enable nurses
and participants to personalise skills training. Finally, due to the small pre-post changes
in the measurements we decided to shift to Experience Sampling Method (ESM) as our
primary outcome for the upcoming RCT. Therefore, with regard to the primary outcome,
this feasibility study was not informative anymore for a power analysis. We found that
using a recovery questionnaire such as the RAS is not sensitive enough to find
differences in the divergent recovery themes that patients stipulated in the interviews
[51]. Therefore, in the upcoming RCT (See for study protocol: www.isrctn.com/
ISRCTN14282228) [52] our primary outcome will be connectedness (CHIME) as a part of
the recovery process [9]. This will be operationalised by measuring social contact in
everyday life with the ESM. Participants will answer questions about the amount of
contact, the quality and the persons they had social interactions with. The questionnaire
is based on previous research [30]. ESM measures real world phenomena and is therefore
considered a suitable method to evaluate the efficacy of interventions that focus on
experiences and functioning in everyday life [53]. In a multicentre RCT the effects of the
modified HospitalitY intervention will be evaluated.

Conclusions
The HospitalitY intervention was well received by participants and nurses. Participants
were motivated to work on personal goals. Also, positive changes in personal recovery
topics were reported by participants. The feasibility study led to refinement of the
intervention. A multicentre RCT will be organised to evaluate the effects of the

33
 HospitalitY intervention on social contact and recovery outcomes.

Funding
Grant support was received from the Roos Foundation, Groningen, The Netherlands,
Chamber of Commerce Groningen, nr: 02085795.

34
References

[1] Jääskeläinen E, Juola P, Hirvonen N, McGrath JJ, Saha S, Isohanni M et al. A systematic review and meta-
analysis of recovery in schizophrenia. Schizophr Bull 2013;39:1296-1306.
[2] Revier CJ, Reininghaus U, Dutta R, Fearon P, Murray RM, Doody GA et al. Ten-Year Outcomes of First-Episode
Psychoses in the MRC AESOP-10 Study. J Nerv Ment Dis 2015;203:379-386.
[3] Gunzler D, Sajatovic M, McCormick R, Perzynski A, Thomas C, Kanuch S et al. Psychosocial Features of
Clinically Relevant Patient Subgroups With Serious Mental Illness and Comorbid Diabetes. Psychiatr Serv
2017;68:96-99.
[4] Bellack AS, Green MF, Cook JA, Fenton W, Harvey PD, Heaton RK et al. Assessment of community functioning
in people with schizophrenia and other severe mental illnesses: a white paper based on an NIMH-sponsored
workshop. Schizophr Bull 2007;33:805-822.
[5] Sharaf AY, Ossman LH, Lachine OA. A cross-sectional study of the relationships between illness insight,
internalized stigma, and suicide risk in individuals with schizophrenia. Int J Nurs Stud 2012;49:1512-1520.
[6] Noiseux S, Ricard N. Recovery as perceived by people with schizophrenia, family members and health
professionals: a grounded theory. Int J Nurs Stud 2008;45:1148-1162.
[7] Davidson L, Roe D. Recovery from versus recovery in serious mental illness: One strategy for lessening
confusion plaguing recovery. J Ment Health 2007;16:459-470.
[8] Anthony WA. Recovery from mental illness: the guiding vision of the mental health system in the 1990s.
Innovations and Research 1993;2:17-24.
[9] Leamy M, Bird V, Le Boutillier C, Williams J, Slade M. Conceptual framework for personal recovery in mental
health: systematic review and narrative synthesis. Br J Psychiatry 2011;199:445-452.
[10] Kopelowicz A, Liberman RP, Zarate R. Recent advances in social skills training for schizophrenia. Schizophr
Bull 2006;32 Suppl 1:S12-23.
[11] Liberman RP, Glynn S, Blair KE, Ross D, Marder SR. In vivo amplified skills training: promoting generalization
of independent living skills for clients with schizophrenia. Psychiatry 2002;65:137-155.
[12] Lyman DR, Kurtz MM, Farkas M, George P, Dougherty RH, Daniels AS et al. Skill building: assessing the
evidence. Psychiatr Serv 2014;65:727-738.
[13] Glynn SM, Marder SR, Liberman RP, Blair K, Wirshing WC, Wirshing DA et al. Supplementing clinic-based
skills training with manual-based community support sessions: effects on social adjustment of patients with
schizophrenia. Am J Psychiatry 2002;159:829-837.
[14] Reichenberg A, Harvey PD. Neuropsychological impairments in schizophrenia: Integration of performance-
based and brain imaging findings. Psychol Bull 2007;133:833-858.
[15] Velligan DI, Mahurin RK, Diamond PL, Hazleton BC, Eckert SL, Miller AL. The functional significance of
symptomatology and cognitive function in schizophrenia. Schizophr Res 1997;25:21-31.
[16] Velligan DI, Tai S, Roberts DL, Maples-Aguilar N, Brown M, Mintz J et al. A randomized controlled trial
comparing cognitive behavior therapy, cognitive adaptation training, their combination and treatment as
usual in chronic schizophrenia. Schizophr Bull 2015;41:597-603.
[17] Bird V, Leamy M, Tew J, Le Boutillier C, Williams J, Slade M. Fit for purpose? Validation of a conceptual
framework for personal recovery with current mental health consumers. Aust N Z J Psychiatry 2014;48:644-653.
[18] Soundy A, Stubbs B, Roskell C, Williams SE, Fox A, Vancampfort D. Identifying the facilitators and processes
which influence recovery in individuals with schizophrenia: a systematic review and thematic synthesis. J Ment
Health 2015;24:103-110.
[19] Castelein S, Mulder PJ, Bruggeman R. Guided peer support groups for schizophrenia: a nursing
intervention. Psychiatr Serv 2008;59:326.
[20] Repper J, Carter T. A review of the literature on peer support in mental health services. J Ment

35
 Health2011;20:392-411.
[21] Vandewalle J, Debyser B, Beeckman D, Vandecasteele T, Deproost E, Van Hecke A et al. Constructing a
positive identity: A qualitative study of the driving forces of peer workers in mental health-care systems. Int J
Ment Health Nurs 2018;1:378-389.
[22] Chinman M, George P, Dougherty RH, Daniels AS, Ghose SS, Swift A et al. Peer Support Services for
Individuals With Serious Mental Illnesses: Assessing the Evidence. Psychiatr Serv 2014;65:429-441.
[23] Lloyd-Evans B, Mayo-Wilson E, Harrison B, Istead H, Brown E, Pilling S et al. A systematic review and meta-
analysis of randomised controlled trials of peer support for people with severe mental illness. BMC Psychiatry
2014;14:39-244X.
[24] Savla GN, Vella L, Armstrong CC, Penn DL, Twamley EW. Deficits in domains of social cognition in
schizophrenia: a meta-analysis of the empirical evidence. Schizophr Bull 2013;39:979-992.
[25] Grant PM, Beck AT. Defeatist beliefs as a mediator of cognitive impairment, negative symptoms, and
functioning in schizophrenia. Schizophr Bull 2009;35:798-806.
[26] Liberman RP, Kopelowicz A. Recovery from Schizophrenia: A Concept in Search of Research. Psychiatr Serv
2005;56:735-742.
[27] Mueser KT. Should psychosocial treatment for schizophrenia focus on the proximal or distal consequences
of the disorder? J Ment Health 2012;21:525-530.
[28] Baart A. Een theorie van de presentie. 3rd ed., Boom Lemma, Utrecht; 2004.
[29] Gard DE, Sanchez AH, Starr J, Cooper S, Fisher M, Rowlands A et al. Using self-determination theory to
understand motivation deficits in schizophrenia: the 'why' of motivated behavior. Schizophr Res
2014;156:217-222.
[30] Granholm E, Ben-Zeev D, Fulford D, Swendsen J. Ecological Momentary Assessment of social functioning in
schizophrenia: impact of performance appraisals and affect on social interactions. Schizophr Res
2013;145:120-124.
[31] Stiekema AP, Quee PJ, Dethmers M, van den Heuvel, E R, Redmeijer JE, Rietberg K et al. Effectiveness and
cost-effectiveness of cognitive adaptation training as a nursing intervention in long-term residential patients
with severe mental illness: study protocol for a randomized controlled trial. Trials 2015;16:49-015.
[32] Bulechek GM, Howard HK, Dochterman JM, Wagner CM. Verpleegkundige Interventies. Vertaling van
Nursing Interventions Classification (NIC). Bohn Stafleu van Loghum, Houten; 2016.
[33] Krasny-Pacini A, Hiebel J, Pauly F, Godon S, Chevignard M. Goal attainment scaling in rehabilitation: a
literature-based update. Ann Phys Rehabil Med 2013;56:212-230.
[34] Kraus DR, Castonguay L, Boswell JF, Nordberg SS, Hayes JA. Therapist effectiveness: implications for
accountability and patient care. Psychother Res 2011;21:267-276.
[35] Morosini PL, Magliano L, Brambilla L, Ugolini S, Pioli R. Development, reliability and acceptability of a new
version of the DSM-IV Social and Occupational Functioning Assessment Scale (SOFAS) to assess routine social
functioning. Acta Psychiatr Scand 2000;101:323-329.
[36] Corrigan PW, Salzer M, Ralph RO, Sangster Y, Keck L. Examining the factor structure of the recovery
assessment scale. Schizophr Bull 2004;30:1035-1041.
[37] Boevink W, Kroon H, Delespaul P, Van Os J. Empowerment according to Persons with Severe Mental Illness:
Development of the Netherlands Empowerment List and its Psychometric Properties. Open J Psychiatry
2017;7:18-30.
[38] Lubben J, Blozik E, Gillmann G, Iliffe S, von Renteln Kruse W, Beck JC et al. Performance of an abbreviated
version of the Lubben Social Network Scale among three European community-dwelling older adult
populations. Gerontologist 2006;46:503-513.
[39] Priebe S, Huxley P, Knight S, Evans S. Application and results of the Manchester Short Assessment of
Quality of Life (ManSA). Int J Soc Psychiatry 1999;45:7-12.

36
[40] Huo T, Guo Y, Shenkman E, Muller K. Assessing the reliability of the short form 12 (SF-12) health survey in
adults with mental health conditions: a report from the wellness incentive and navigation (WIN) study. Health
Qual Life Outcomes 2018;16:34-018.
[41] Wallace CJ, Liberman RP, Tauber R, Wallace J. The independent living skills survey: a comprehensive
measure of the community functioning of severely and persistently mentally ill individuals. Schizophr Bull
2000;26:631-658.
[42] Konings M, Bak M, Hanssen M, van Os J, Krabbendam L. Validity and reliability of the CAPE: a self-report
instrument for the measurement of psychotic experiences in the general population. Acta Psychiatr Scand
2006;114:55-61.
[43] World Medical Association (WMA). Declaration of Helsinki. Amended by the 64th WMA General Assembly,
Fortaleza, Brazil. WMA Archives, Ferney-Voltaire, France; 2013.
[44] American Psychiatric Association., American Psychiatric Association. Diagnostic and statistical manual of
mental disorders: DSM-IV-TR, American Psychiatric Association, Washington, DC; 2000.
[45] Gard DE, Sanchez AH, Starr J, Cooper S, Fisher M, Rowlands A et al. Using Self-Determination Theory to
Understand Motivation Deficits in Schizophrenia: The ‘Why’ of Motivated Behavior. Schizophr Res
2014;156:217-222.
[46] Castelein S, Bruggeman R, van Busschbach JT, van der Gaag M, Stant AD, Knegtering H et al. The
effectiveness of peer support groups in psychosis: a randomized controlled trial. Acta Psychiatr Scand
2008;118:72.
[47] Bellack AS. Scientific and consumer models of recovery in schizophrenia: concordance, contrasts, and
implications. Schizophr Bull 2006;32:432-442.
[48] Liberman RP. Recovery from schizophrenia: form follows functioning. World Psychiatry 2012;11:161-162.
[49] Stevens A, Beurskens A, Koke A, van der Weijden T. The use of patient-specific measurement instruments in
the process of goal-setting: a systematic review of available instruments and their feasibility. Clin Rehabil
2013;27:1005-1019.
[50] Liberman RP, Kopelowicz A, Silverstein SM. Psychiatric rehabilitation. In Sadock BJ, Sadock VA, eds.
Textbook of Psychiatry. Comprehensive ed., Lippincott Williams and Wilkins, Baltimore, Md; 2005.
[51] Shanks V, Williams J, Leamy M, Bird VJ, Le Boutillier C, Slade M. Measures of personal recovery: a systematic
review. Psychiatr Serv 2013;64:974-980.
[52] Vogel JS, Liemburg EJ, Gaag van der M, Castelein S. Hospitality project (HY): Combining peer support and
home-based skill training in people with schizophrenia. ISRCTN Register Biomed Central 2016;DOI 10.1186/
ISRCTN14282228 ISRCTN Register Biomed Central.
[53] Myin-Germeys I, Birchwood M, Kwapil T. From environment to therapy in psychosis: a real-world
momentary assessment approach. Schizophr Bull 2011;37:244-247.

37