{"id":10513,"date":"2026-04-09T13:15:02","date_gmt":"2026-04-09T13:15:02","guid":{"rendered":"https:\/\/www.proefschriftmaken.nl\/portfolio\/sarita-sanches\/"},"modified":"2026-04-23T07:27:04","modified_gmt":"2026-04-23T07:27:04","slug":"sarita-sanches","status":"publish","type":"us_portfolio","link":"https:\/\/www.proefschriftmaken.nl\/en\/portfolio\/sarita-sanches\/","title":{"rendered":"Sarita Sanches"},"content":{"rendered":"","protected":false},"excerpt":{"rendered":"","protected":false},"author":8,"featured_media":12636,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_acf_changed":false,"footnotes":""},"us_portfolio_category":[45],"class_list":["post-10513","us_portfolio","type-us_portfolio","status-publish","has-post-thumbnail","hentry","us_portfolio_category-new-template"],"acf":{"naam_van_het_proefschift":"WORKING TOWARDS SOCIAL PARTICIPATION","samenvatting":"Er is geen Nederlandse samenvatting beschikbaar. De Engelse samenvatting vind je <a href=\"https:\/\/www.proefschriftmaken.nl\/en\/portfolio\/sarita-sanches\/\">hier<\/a>.","summary":"These subgroups differ from each other with respect to age, duration in MHC, living situation, educational level, the presence or absence of a life partner, needs for care regarding social contacts, quality of life, psychosocial functioning, and psychiatric symptoms. No differences were found with respect to clinical diagnosis or gender. Each subgroup presents specific challenges, which underlines the need for tailored rehabilitation interventions. Special attention is needed for people who are involuntarily inactive, with severe psychiatric symptoms and problems in psychosocial functioning as this seems to be a particularly vulnerable subgroup.\n\nSupporting people with SMIs in reaching personal goals is a core aspect of psychiatric rehabilitation. This core aspect is addressed in chapter 3, which aims to find which aspects of the working alliance are predictive of successful rehabilitation goal attainment in individuals with SMIs. Also, the underlying assumption that rehabilitation goal attainment improves quality of life was tested on its validity. To investigate this, secondary multiple logistic and multiple regression analyses were conducted of data from the randomized controlled trial (RCT) on goal attainment by people supported with BPR (N=80) versus a generic approach (N=76), that was performed previously by members of the research group. The current study showed that rehabilitation goal attainment at 24 months was significantly predicted by a specific aspect of the working alliance, namely the agreement on goals. No effects were found for agreement on tasks or the bond between patient and practitioner. Furthermore, successful goal attainment significantly predicted quality of life at 24 months. These effects were independent of the rehabilitation approach used (i.e. independent of the positive effect of BPR on rehabilitation goal attainment). The conclusion of the study was that a good bond between patient and practitioner is not enough to successfully work on rehabilitation goals. The findings suggest that it is important to discuss patients\u2019 wishes and ambitions and form an agreement on the goals to be achieved. Also, attaining rehabilitation goals directly influenced the subjective quality of life of individuals with SMIs, which underscores the importance of psychiatric rehabilitation for this group of people.\n\nTo investigate whether BPR would be an effective and cost-effective method to improve the social participation of people with SMIs, a randomized controlled trial was designed and conducted. In chapter 4, the design and methods of the trial are elaborately outlined (Trial registration: Current Controlled Trials: ISRCTN88987P22. Registered 13 May 2014). The study was designed as a multi-site RCT, in which 250 adults (18\u201364 years of age) with SMIs would be randomly allocated to the experimental (BPR) or the active control condition (ACC). All participants were offered support aimed at personal rehabilitation goals and monitored over a one-year period. Outcomes were measured at baseline, and at 6 and 12 months after enrolment. The results of the study are described in Chapter 6.\n\nChapter 5 describes the feasibility and psychometric analysis of an instrument developed to assess the model fidelity of working with BPR in Dutch mental health care. The instrument is intended to measure and improve the degree of BPR model fidelity and the competence of the BPR practitioner at an individual level and within individual rehabilitation processes. It is based on two previous versions of instruments for measuring BPR model fidelity and was developed with (inter)national BPR experts. The final instrument has been named Fidelity of Rehabilitation (FiRe). With FiRe, the extent to which individual practitioners correctly apply the different BPR techniques is derived from written progress reports about the sessions, and assessed on a scale ranging from 1 (lowest level of model adherence) to 5 (highest level of model adherence). In this study, the content of 114 individual rehabilitation processes was documented by the 27 rehabilitation practitioners who delivered the approach. Rotating pairs of four BPR specialists used FiRe to evaluate the degree of BPR model fidelity as described in these written progress reports. The results showed that interrater reliability was good (.66) as were correlations between the first and second assessments (.74). FiRe was able to distinguish between IRB experts and non-experts, expressing concurrent validity. Scores on FiRe were also related to rehabilitation attitude, a potentially similar construct. In this study, the average level of BPR model fidelity was low (in almost 70% of the trajectories, practitioners received FiRe scores of 1 - 2.5). Overall FiRe scores improved slightly during the 10.5-month study period, but this effect was not significant. Nevertheless, practitioners reported that the FiRe-based feedback they received helped them improve their BPR skills. It was concluded that this first version of FiRe is a valid and reliable instrument with which to gain insight into the quality and fidelity of individual BPR practitioners\u2019 rehabilitation practices. The instrument used in this study will be further developed in line with study results. More importantly, FiRe raises questions about the definition of \u201cgood BPR\u201d, a topic that should be explored more extensively in future research.\n\nChapter 6 investigated the effectiveness of BPR with respect to improving the social participation of people with SMIs. BPR was compared to an active control condition (ACC), in which practitioners had also been explicitly instructed to work on personal rehabilitation goals (see the description of the study in Chapter 4). A randomized controlled trial was conducted among 188 people with SMIs (BPR=98; ACC=90) at Altrecht Institute for Mental health Care, Parnassia Psychiatric Institute (formerly Dijk and Duin), Cosis (formerly Promens Care), Lister and Brijder. Multilevel modeling showed that participants in both groups improved their level of social participation, quality of life and psychosocial functioning during the study period. BPR however, was not found to be more effective than ACC on any of the primary or secondary outcome measures. Greater social participation was predicted by prior work experience and a lower intensity of psychiatric symptoms. The lack of a significant effect of BPR could be due to the fact that practitioners in ACC were significantly more likely to engage help from specialist employment services including IPS job coaches, even though engaging additional help was allowed in both conditions. It is also possible that ACC has become more focused on the importance of psychiatric rehabilitation in recent years and that this has reduced the difference between the two conditions. Low adherence to BPR model fidelity could also be a possible explanation for the lack of an effect. However, the per-protocol analysis did not confirm this. By extension, BPR might be difficult to implement due to its complex and layered nature. Furthermore, almost half of the study participants wanted paid work and BPR was not specifically developed to attain these types of goals. Finally, external factors such as changes in legislation and regulation during the study period and the economic recession may have had an influence. It was concluded that in this study sample, ACC was as effective as BPR with respect to improving the social participation of individuals with SMIs. The percentages of study participants who found (paid) work or other meaningful activities were around 43% (paid work 31%) and this is much higher than in observational studies without specific support for social participation where percentages around 4% are found. Therefore, it is suggested that focused rehabilitation efforts are beneficial, irrespective of the specific methodology used.\n\nChapter 7 presents the cost-effectiveness and budget impact of BPR based on data gathered in the RCT described in chapter 4 and 6. Costs were assessed with the Treatment Inventory of Costs in Patients with psychiatric disorders (TIC-P). Outcome measures for the cost-effectiveness analysis were incremental cost per Quality Adjusted Life Year (QALYs) and incremental cost per proportional change in social participation. Budget impact was investigated using four different implementation scenarios. The results showed that total costs per participant at 12-month follow-up were \u20ac12,886 in BPR and \u20ac12,012 in ACC, a non-significant difference. The types of expenditures in which the most costs were incurred were supported and sheltered housing, inpatient care, outpatient care, and participation in organized activities. Total intervention costs after 12 months were \u20ac550 in BPR and \u20ac490 in ACC. BPR was not found to be cost-effective with regard to social participation or QALYs. Estimated budget impact ranged from cost savings to \u20ac190 million, depending on the exact implementation scenario. It was concluded that BPR is not a cost-effective method for improving the social participation of people with SMIs, compared to ACC. As the cost-effectiveness of BPR was investigated in the area of social participation, while BPR is designed to offer support in all rehabilitation areas, the results should not be applied to the method as a whole.\n\nDiscussion (Chapter 8)\n\nFinally, chapter 8 provides an integration of the results, and a general discussion placing the findings in a broader context. Six main themes are discussed. The first main theme for discussion is the ongoing need for support with social participation for the target population. Over the past 30 years, many studies have been conducted demonstrating the need for and the many benefits of social participation, particularly paid employment. However, the rates of individuals with SMIs that actively participate in society have remained low during this period. Not only when compared to the general population, but also when compared to people with physical disabilities. This is worrying as social participation is an important facilitator of quality of life, and associated with many (mental) health benefits. Low participation levels also translate into high costs for society. This shows that there is still ongoing need for support with social participation for individuals with SMIs.\n\nThe second main theme for discussion is the relationship between social participation and community integration, and the role of stigma within this relationship. Both social participation and community integration are core aspects of psychiatric rehabilitation methods. Social participation is an important aspect of community integration. Community integration can be hampered by personal as well as environmental factors - stigmatization in particular. Stigmatization is the process of negatively labeling, condemning and excluding a group of individuals, in this case people with SMIs. It has serious consequences such as creating social distance between people with SMIs and the general public. That stigmatization is a frequently encountered problem is illustrated by the fact that approximately 75% of members of a Dutch panel of people with SMIs indicated they had experienced some form of stigma in the past two years. Psychiatric rehabilitation could play an important role in reducing stigmatization, as working on personal goals increases self-esteem and a positive self-image, and decreases fear of rejection or negative reactions from other people. It may also help decrease public stigma by showing the general public that people with SMIs can fulfill various social roles. Utilizing experiential knowledge is a key ingredient of modern anti-stigma interventions, for any target group. Fortunately, the necessity of combatting stigma is increasingly recognized by various stakeholders, and the topic has found its way into global research agendas.\n\nThe third main theme for discussion is the vital importance of targeted and expert support in order to improve the social participation of people with SMIs. This becomes clear when the rates of attained social participation goals described in chapter 6 are compared to naturalistic studies in which no targeted support with social participation is provided. These naturalistic studies show that although many people with SMIs want to increase their social participation, only few are able to do so without professional assistance. The question that arises from this fact is: does rehabilitative support receive enough attention in MHC? In recent years, MHC organizations have increasingly adopted a recovery-oriented vision, which includes attention to psychiatric rehabilitation. However, despite this development, support with recovery and social participation is not always integrated in daily practice. The fact that there is a need for more professional support in realizing social participation goals in mental healthcare, is underlined by the observation made earlier in this chapter that the participation rates of people with SMIs have remained relatively stable over the past 30 years. This suggests that a growing awareness for recovery and rehabilitation among MHC professionals is not enough to promote the social inclusion of people with SMIs. It is critical that MHC professionals not only become aware of the importance of recovery and social participation, but also have the opportunity and time to provide the required support. If necessary skills or knowledge are lacking, it should be possible to involve or refer to more specialized services. Furthermore, structural implementation of evidence-based psychiatric rehabilitation methods is needed, which is only possible with sufficient financial, administrative, and political support.\n\nThe fourth main theme for discussion is the influence of the economic and legal context in which the study on BPR effectiveness was conducted. The study on BPR effectiveness was conducted from March 2014 to August 2017. During this period, the Netherlands was still recovering from an economic recession caused by the global credit crisis, and the unemployment rate was relatively high. People with a pre-existing distance to the labor market -such as our study participants- became particularly vulnerable during the economic downturn, because there was a general difficulty in finding jobs, and they had not been able to take advantage of better economic conditions. Parallel to the economic recession, changes in Dutch legislation occurred, starting with the introduction of the Participation Act (NL: Participatiewet), and the new social support act (Dutch: wet maatschappelijke ondersteuning (wmo)) in 2015. These acts caused tasks that were originally the responsibility of the mental health sector to shift to local governments, with extensive transitions in both funding and services. In many cases, this shift caused problems for people with SMIs, including our study participants. For instance, study participants could be limited in their opportunities to spend more hours in organized daily activities, or to enroll in education, because funding was lacking. In some cases, this could seriously hamper the attainment of personal rehabilitation goals.\n\nA fifth main theme for discussion is the suitability of BPR as a rehabilitation method to improve social participation. A strength of BPR is that it is a broad approach that can be used to provide support in all rehabilitation areas. However, a possible disadvantage of a broad approach is that it may be less suitable for goals in very specific areas such as competitive employment or education. More specialized methods such as IPS or supported education -which has its roots in BPR- may be more effective for individuals with these types of goals. An interesting finding in the RCT on BPR effectiveness (chapter 6), was that practitioners in ACC engaged external resources such as job coaches significantly more often than BPR practitioners. Involving other resources when needed is an important part of BPR. However, this component is only addressed in an advanced part of BPR training and not all BPR practitioners in our study had completed this part of training. In line with that, perhaps BPR training should adopt the concept of the T-shaped professional. This means having both deep, specialist knowledge about rehabilitation, but also the abilities and competencies to connect with professionals from other disciplines, without abandoning BPR\u2019s core principle that the wishes of the individual with SMIs should be leading the rehabilitation process.\n\nThe studies described in chapters 5 and 6 show that rehabilitation processes are not always conducted according to model guidelines. Possible reasons for this could be deviation from protocol (\u2018program drift\u2019), lack of time to write full progress reports, or perhaps the fact that BPR might be too complex for the average social worker with its distinct jargon, layered nature and high level of detail. In response to these criticisms and the results of this study, Rehabilitation \u201892, the organization that provides training in and support with BPR implementation in the Netherlands, continues to update and improve existing teaching materials. Whether their adaptations will have an effect on BPR fidelity and effectiveness will have to be subject of future evaluations.\n\nAs the sixth main theme for discussion, the strengths and limitations of the studies described in this thesis are discussed. The first strength is the use of a broad definition of social participation that includes not only competitive employment, but also unpaid employment, education, and other meaningful daily activities. This is important because competitive employment has many benefits but is not always a viable option for people with SMIs. It is also not always desired. The second strength is the identification of factors that predict social participation (chapter 2) and rehabilitation success (chapter 3). This information is needed to optimize existing psychiatric rehabilitation methodologies, and tailor rehabilitation programs to the different needs of service users. A third strength is that the studies described in chapters 6 and 7 contribute to the knowledge of BPR. Despite the fact that BPR has been implemented in MHC in several countries and has influenced the way recovery is viewed, little research has been conducted on its effectiveness, and until now, none on its cost-effectiveness. The fourth and final strength is that we have conducted the only cost-effectiveness study on BPR to date. The cost-effectiveness study provides insight into the various costs associated with the care for individuals with SMIs, which may be of particular use to those making policy that affects the target group.\n\nThe first limitation related to the design of the main study and the research process was inclusion problems. The main study (chapters 6 and 7) faced serious problems with regard to the inclusion of participants. As a consequence, it took eight months longer than expected to complete the inclusion period. The second limitation was difficulties in establishing contact between BPR practitioner and study participant. Some BPR and ACC practitioners found it hard to establish contact with their assigned participant, or vice-versa. As a result, not all rehabilitation processes were initiated. The third limitation was the short follow-up period. Psychiatric rehabilitation takes time and a one-year follow-up period may have been too short, particularly for the cost-effectiveness study. The previous Dutch RCT on the effectiveness of BPR had a follow-up period of two years and the number of attained goals increased substantially between the first and second year.\n\nChapter 8 also provides implications for clinical practice and recommendations for future research, based on the study results. Implications for clinical practice are that attention and structural support should be given to the social participation of people with SMIs. This should include attention to specific personal rehabilitation goals rather than taking a more general and open approach towards rehabilitation. Because attention to personal rehabilitation goals is a central feature of BPR, this could be a good method of providing the needed support with social participation. However, the research in Chapter 6 showed that BPR did not work better than ACC in this area. When making decisions on reimbursement or implementation of BPR, it must be realized that we evaluated BPR within the very specific context of social participation, whereas BPR was originally intended to provide support in all rehabilitation areas. Therefore, the results cannot simply be applied to the method as a whole. In the main study in Chapter 6, 31% of all goals in the area of paid employment were achieved. This is much higher than the percentages (around 4%) found in studies where no psychiatric rehabilitation support is provided. It is, therefore, important that psychiatric rehabilitation is widely implemented and available to all MHC consumers.\n\nRecommendations for future research are to develop an overarching research program for psychiatric rehabilitation using the knowledge cycle as a tool to aid this development. In developing such a program it is important to involve consumers \/ experts by experience in all phases of the knowledge cycle. A methodological recommendation for (funders of) future research is to enable the use of a longer follow-up period, especially when studying cost-effectiveness. This is important to capture both short and long-term outcomes. Rehabilitation research in general should focus more on setting and achieving personal goals as an outcome measure, and ways to measure goal attainment should be optimized. Several tools have been developed to better measure personal goals such as the 2-COM (2-way communication), GAS (goal attainment scaling), and CASIG (Clients Assessment of Strengths, Interests, and Goals). The effectiveness of psychiatric rehabilitation could be further improved by gaining a better understanding of the working mechanisms of BPR. This understanding could also help to further define exactly what good BPR entails. By extension, methods that clarify what works for whom, promote the tailoring of care to individual needs. Specific topics that deserve more research attention are factors that influence social participation, and interventions that focus on social contacts and meaningful daily activities other than paid employment. A separate section in the discussion is devoted to people with severe and enduring eating disorders. Future research should also focus on psychiatric rehabilitation for this group of people since they are often relatively young and exhibit impairments in functioning similar to those seen in people with other SMIs.\n\nThe chapter closes with a general conclusion, which stresses the importance of targeted support with social participation through psychiatric rehabilitation methods for people with SMIs. This support should be available to all people with SMIs. In the main study, BPR did not increase the social participation of people with SMIs more than ACC; both approaches were found to increase the social participation of people with EPA. Also, the intervention was not cost-effective compared to ACC. There may be several reasons for not finding a greater effect for BPR, for instance the fact that a large number of participants wanted paid employment, which may require more specific support. At the individual level, psychiatric rehabilitation outcomes could be improved by focusing on agreement between MHC practitioner and patient about the goals being worked on. At a higher level, outcomes could be improved through systematic implementation of strategies aimed at social participation.","auteur":"Sarita Sanches","auteur_slug":"sarita-sanches","publicatiedatum":"7 april 2021","taal":"EN","url_flipbook":"https:\/\/ebook.proefschriftmaken.nl\/ebook\/saritasanches?iframe=true","url_download_pdf":"","url_epub":"","ordernummer":"FTP-202604091310","isbn":"978-94-6423-177-9","doi_nummer":"","naam_universiteit":"Tilburg University","afbeeldingen":12636,"naam_student:":"","binnenwerk":"","universiteit":"Tilburg University","cover":"","afwerking":"","cover_afwerking":"","design":""},"_links":{"self":[{"href":"https:\/\/www.proefschriftmaken.nl\/en\/wp-json\/wp\/v2\/us_portfolio\/10513","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.proefschriftmaken.nl\/en\/wp-json\/wp\/v2\/us_portfolio"}],"about":[{"href":"https:\/\/www.proefschriftmaken.nl\/en\/wp-json\/wp\/v2\/types\/us_portfolio"}],"author":[{"embeddable":true,"href":"https:\/\/www.proefschriftmaken.nl\/en\/wp-json\/wp\/v2\/users\/8"}],"replies":[{"embeddable":true,"href":"https:\/\/www.proefschriftmaken.nl\/en\/wp-json\/wp\/v2\/comments?post=10513"}],"version-history":[{"count":1,"href":"https:\/\/www.proefschriftmaken.nl\/en\/wp-json\/wp\/v2\/us_portfolio\/10513\/revisions"}],"predecessor-version":[{"id":10514,"href":"https:\/\/www.proefschriftmaken.nl\/en\/wp-json\/wp\/v2\/us_portfolio\/10513\/revisions\/10514"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/www.proefschriftmaken.nl\/en\/wp-json\/wp\/v2\/media\/12636"}],"wp:attachment":[{"href":"https:\/\/www.proefschriftmaken.nl\/en\/wp-json\/wp\/v2\/media?parent=10513"}],"wp:term":[{"taxonomy":"us_portfolio_category","embeddable":true,"href":"https:\/\/www.proefschriftmaken.nl\/en\/wp-json\/wp\/v2\/us_portfolio_category?post=10513"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}