Chapter 2
Chapter 2
DOI:
10.33612/diss.217103261
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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.
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.
• 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.
• 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.
• 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.
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.
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
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