The resource group method in severe mental illness: study protocol for a randomized controlled trial and a qualitative multiple case study

Traditionally, severe mental illnesses (SMI) were seen as chronic diseases with relapsing or deteriorating symptoms and poor prognoses [1, 2]. Recovery was perceived as a medical outcome defined by remission of mental health symptoms [3]. Due to the consumer movement, a new view emerged in psychiatry in the 1990s [4, 5]. Within this view, recovery is conceptualized as a unique, personal and ongoing process of growth that involves learning to live with one’s disability despite the limitations of symptoms, and gradually rebuilding a sense of purpose, agency, and meaning in life [5‐7].

This conceptualization of recovery was incorporated within the development of new working models for organizing mental healthcare. One of these models is Flexible Assertive Community Treatment (Flexible ACT) [8] that was established in the Netherlands as a Dutch variant of Assertive Community Treatment (ACT) [9]. Flexible ACT teams deliver services for an entire group of people with SMI in a particular region by adapting a flexible switching system between standard community mental healthcare and an intensive ACT equivalent [8, 10]. This combination of flexibility and continuity of care provides opportunities for combining recovery-oriented care with evidence-based medicine, best practices and integrated community and hospital care.

However, an examination of the model fidelity of FACT teams between 2009 and 2014 showed that support of recovery, rehabilitation and participation was implemented insufficiently [11]. Similar findings were shown by a nationwide survey in 2016, which reported that over 80% of patients with SMI experienced feelings of loneliness, that 40% did not feel that they were part of society, and that only 20% had paid or unpaid employment [12]. Second, although the informal support system is perceived as an important factor in supporting recovery and participation and the effectiveness of involving significant others in SMI care is well established, it has been found that systematic and formal forms of support and contact with family members are seldom achieved [3, 11, 13, 14]. These implementation problems justify the ongoing search for a mental health service that empowers patients with SMI, by stressing their choice and autonomy and by encouraging social connectedness and participation.

A structured method for reinforcing empowerment and social connectedness in mental healthcare is represented by the resource group method. In short, to constitute a resource group (RG), patients nominate significant others from their informal network (such as friends and family) and their formal network (such as a social worker or job-coach). During the frequent RG meetings, the RG discusses patients’ goals and wishes, and jointly determines a recovery plan to achieve them.

The first important characteristic of the RG method is that patients themselves take the lead in any decisions: they nominate the members of their RG, set their recovery goals and determine important aspects of how the RG meetings are designed [15]. Considering these decisions is a crucial factor in patients’ sense of autonomy and sense of ownership of their treatment. Patients are then encouraged to extend this to autonomy and ownership of their illness (such as their ability to cope with symptoms) and regarding other social and community aspects of life. This process of regaining control over one’s life—despite the need for support—is a key concept of empowerment, and is regarded as an important driving force in recovery [16, 17].

The second important characteristic of the RG method is that significant others are systematically engaged in treatment and care [18]. As a patient and his or her significant others form a team together with involved professionals, support in the recovery plan is broadened. Hereby, the fulfillment of a meaningful life and everyday activities is strengthened. In other words, through collaboration—joint discussion of patients’ wishes and needs, and creating space for sharing experiences and emotions—an empowered and supportive social environment can be built to supplement professional care. Having such environment in turn, is assumed to foster resilience and continuity in social and community integration. Improved integration and a feeling of connectedness are seen as facilitators and indicators of recovery [1, 19‐21].

Also, it is increasingly recognized that significant others need social support to break isolation and reduce stigma [22, 23]. Moreover, studies investigating experiences with care report that families feel marginalized, uninformed, lack a recognized role and distanced from the care planning process [24‐26]. Therefore, a structured and more frequent contact between professionals and significant others would meet with their need to feel more part of the treatment and care. Additionally, professional support and attention to the consequences of the patients’ disease for the personal wellbeing of the important people around the patient, may reduce their burden, increase their sense of security, and improve their own mental health status [13, 27, 28]. Moreover, during the RG meetings all involved professional caregivers from different sectors (e.g., mental health, social affairs, housing and employment) can be invited. In this way, the RG method responds to the need to improve communication between all those involved, pursuing a consistent and collaborative model of integrated care.

In sum, the RG method structures the care and support that is built around patients’ personal choices, wishes and aspirations. It focuses on creating a mental health system that encourages patients to be active, informed and autonomous participants who, by collaborating with their social environment, can develop the support that meets their needs and chosen lifestyle. By systematically engaging patients’ significant others, continuity in support is embedded. Eventually, it is hoped, a resilient, empowered social support system can be created that functions independently of professional resources. As the RG method thus has great potential for promoting the autonomy, empowerment and recovery of patients with SMI, it may bring valuable improvements to standard FACT. The origins of the RG method lay in the Optimal Treatment (OT) model, which integrates biomedical, psychological and social strategies in the management of SMI [29, 30]. It was shown in a meta-analysis of the effectiveness of variations of the OT model for patients with a psychotic disorder (N = 2263, 6 randomized studies, 11 observational studies, follow-up between 12 and 60 months) that participation in the OT model led to clinically significant improvements. Relative to care as usual, it improved functioning (Cohen’s d = 0.82), increased well-being (d = 0.88) and reduced symptoms (d = 0.72) [31]. Similarly, a systematic review of eight RCTs showed that the OT program improved symptoms, functioning and well-being in patients with a psychotic disorder [18]. In Sweden, the “family unit in the community” was regarded as a central element of the OT model, and was further developed as the concept of the “resource group” [32]. To reflect the key role of the RG and to integrate it into the existing mental healthcare programs for patients with SMI, the Swedish OT program was relabeled as Resource Group Assertive Community Treatment (RACT) [33, 34]. In this way, ACT teams [9] were enriched and augmented by resource groups involving patients and their network in clinical case management by shared decision making procedures.

This study is intended to add to the existing research in three ways. First, in the studies included in the meta-analysis and review referred to above, integrated care models related to the RACT program were assessed. However, no study has investigated the specific additional value of the RG method in a head-to-head comparison with FACT. Second, previous studies focused on patients with psychotic disorders. Knowledge is lacking about the effectiveness of the RG method for patients across the entire psychiatric spectrum. The third contribution is intended to provide in-depth understanding of the meaning of the experiences in using the RG method to those involved. Very few qualitative contributions have been conducted. As most focused mainly on the case-managers’ point of view [33], they overlooked the experiences and perspectives of patients, RG members and other professionals. To better understand the RG method and its implementation, we thus intend to conduct exploratory research that analyses its dynamics and meaning from the perspectives of those involved.

To achieve these objectives, this study consists of a randomized controlled trial (RCT) to establish clinical effectiveness, an economic evaluation and a qualitative case study on the dynamics, meaning and implementation of the RG-method. The primary objective of the study is to determine whether the RG method integrated in FACT is more effective in empowering patients with SMI when compared to standard FACT. Secondary objectives consist of the assessment of the RG method in improving quality of life and enhancing social and community functioning; and, in an economic evaluation, to investigate its cost-effectiveness. An add-on qualitative study will explore the perspectives of those involved and the implementation of the RG method in Dutch mental healthcare.