Federal and state governments are calling for recovery-oriented care and psychiatric rehabilitation services for people with severe mental illnesses (1—3). Psychiatric rehabilitation is the field of evidence-based interventions for people with severe mental illness. Recovery refers to the pursuit of a meaningful life despite the persistence of symptoms of severe mental illness. Psychiatric rehabilitation services include Assertive Community Treatment, Supported Employment, and Illness Management and Recovery (4—10). Psychiatric rehabilitation principles include empowerment of people with severe mental illness and optimism.

Psychiatric residents need to learn psychiatric rehabilitation not only for community psychiatry but for any setting in which they see patients with severe mental illness. In 2000, Freeland et al. (11) published a cross-sectional study of psychiatric residents in five Canadian residency programs. They found that residents were interested in community psychiatry, but their career paths were focused on urban hospital-based practice despite economic pressures to practice in the community. Cohen and colleagues (12) published a description of a fourth postgraduate year (PGY-4) required rotation in community psychiatry intended to increase interest and competence in public sector work, psychiatric rehabilitation, and recovery. They found that the PGY-4 psychiatric residents expressed gratification from their experiences. Interestingly, there was a significant increase in the number who entered public psychiatry fellowships.

There are no controlled or prospective studies of psychiatric residents' attitudes, skills, or knowledge of the evidence-based treatments for severe mental illness. This study assessed whether a 3-month rotation in a psychiatric rehabilitation center changes the competency level of treating severe mental illness in second-year psychiatric residents relative to their nonrotating peers of the same year.

Study Design

A case-control study of PGY-2 residents' competencies in the treatment of severe mental illness was conducted at a large multisite residency program. The case residents were the residents who selected a 3-month rotation in community psychiatry at VA Connecticut during their second year. The remaining residents, who had no formal community psychiatry rotation during their second year, comprised the comparison group. The comparison group rotated through 3-month blocks at other sites such as inpatient units in the Veterans Administration (VA), community mental health center, and/or a university hospital during their PGY-2 year. The study was conducted for 3 academic years, 2005—2008, to increase the number of participants.

In order to measure competency in the treatment of severe mental illness, the Competency Assessment Instrument (13) was administered to case and comparison residents by staff not involved in the residents' performance evaluations. Residents were randomly assigned a code which was printed on the questionnaire at baseline and follow-up. In order to facilitate anonymity, all data were entered and analyzed by code and never linked to residents' names.

Case residents completed the Competency Assessment Instrument (CAI) within the first week of their community psychiatry rotation. They completed it again 3 months later in the last week of the rotation. Comparison residents completed the CAI at the beginning of the PGY-2 year and again at the end of the year. The study was approved by the VA and Yale University Human Investigation Committees.

Sample

All PGY-2 residents rotating on psychiatry services at the time of the study were invited to participate (N=47). Only residents who completed the baseline and follow-up surveys were included in the analyses of change in competency (n=23).

Intervention

The community psychiatry rotation at VA Connecticut was offered as an elective to PGY-2 residents. The residents rotated at the Community Reintegration Program, a psychiatric rehabilitation day program, as an equal member of a multidisciplinary team. Each team member was responsible for the holistic care of people on his or her caseload and consulted other specialists on the team, a model which differs from most inpatient units.

One resident rotated through the community psychiatry rotation approximately every 3 months. When clinically appropriate, the resident visited the home and workplace of veterans on his or her caseload. Crisis intervention was also common during the rotation. Residents were encouraged to focus as much on the personal goals of their clients as on symptoms and medication management.

The resident cofacilitated a cognitive therapy group and a second group with an elective topic. The resident also attended a weekly seminar to learn about recovery-oriented care and evidence-based psychiatric rehabilitation services. In order to illustrate these services, the resident spent a morning with each of the following teams: the Intensive Case Management team, the homeless team visiting shelters and streets, and the supported employment team visiting clients at worksites.

Measures

In order to measure residents' competency in the treatment of people with severe mental illness, the Competency Assessment Instrument (CAI) was administered. The CAI was developed, validated, and psychometrically tested by Chinman et al. (13). It applies to multiple disciplines and is not designed specifically for psychiatrists. The CAI measures 16 provider competencies critical to recovery, rehabilitation, and empowerment of people with severe and persistent mental illness, providing a score for each competency (Table 1). The survey includes items for attitude, knowledge, and skills. Each of the 16 competencies consists of 2—4 survey items. The numeric response for each survey item is subtracted and divided, according to a formula provided by the CAI key, in order to produce a score between 0 (no competence) and 1 (total competence).

Questions were added for the purposes of this study about demographics, choosing to rotate at the community psychiatry site, future plans to work with people with severe mental illness, and previous experience in treatment and rehabilitation of severe mental illness.

Analyses

Demographic variables and all competencies at baseline were compared between the two groups of PGY-2 residents by using chi-square test for categorical variables and t tests for continuous variables. Repeated measures analysis was used to determine the significance of improvement from baseline to follow-up on the 16 competencies for the case and comparison residents. Finally, analysis of variance (ANOVA) was used to compare case and comparison resident scores.

Participants

A total of 43/47 residents (91% response rate) completed the baseline survey (Table 2). Follow up data were available for 53% residents (n=23/43) who completed both the baseline and the postintervention surveys, with significantly more case residents (n=8/11, 73%) than comparison residents (n=15/32, 47%) completing the survey.

Baseline Competencies

There were no significant differences in baseline competencies between case and comparison residents (Table 3). Most of the 16 CAI competencies scored in mid-range (0.5). However, three of the competencies did not score mid-range: stigma, rehabilitation, and intensive case management. By scoring 0.8 for stigma at baseline, both cases and comparison subjects demonstrated high competency in their understanding and interventions around stigma. They demonstrated a lack of competence in the CAI items psychiatric rehabilitation (0.02) and intensive case management (0.24). (The CAI designates rehabilitation as one competency item, whereas we define rehabilitation in the introduction to encompass all the competencies in the CAI.) The rehabilitation items evaluated how seriously the resident takes a client's personal goals and how much the resident believes the client could and will benefit from rehabilitation services such as work therapy. The intensive case management item questioned how often the resident leaves the office with the client, helps a client find services, and assists clients when denied by agencies.

Overall Change in Competencies for Case and Comparison Residents

Participants who completed pre- and postintervention surveys showed significant improvement in three CAI competencies over the course of the PGY-2 year: (a) goal functioning, (b) holistic approach, and (c) family education (Table 4). The goal functioning item included assessing a client's strengths, weaknesses, and level of functioning in relation to a personal goal. The holistic approach item consisted of attitude questions about whether diagnosis predicts the success of rehabilitation, whether the severity of symptoms precludes the ability to work, whether "normal" goals are too stressful for people with severe mental illness, and whether the residents should only talk about symptoms with their clients. The family education item consisted of rating how confident the resident felt in educating families about illness, medication, rehabilitation, and support groups.

Competency in family involvement significantly worsened from the beginning to the end of the year. This item evaluated how often the resident teaches family members about mental illness, gathers information from families, and helps families cope with stress.

Change in Competencies for Case Residents

Relative to the comparison group, the case residents demonstrated significant improvements in five CAI competencies: (a) goal functioning, (b) client preferences, (c) holistic approach, (d) skills advocacy, and (e) team value (Table 5). Client preferences included attitudinal questions about the value of clients' preferences in the consideration of treatment recommendations and how client empowerment affects functioning. Skills advocacy evaluated how often the residents teach clients decision making, self-advocacy, occupational, and medication-taking skills. The team value item included questions about the value of team meetings and collaboration.

Psychiatric residents in PGY-2 learned important skills for the treatment of people with severe mental illness, even without a community psychiatry rotation. These residents rotated through typical settings: a state mental health facility, a VA, and the university hospital. In these settings, residents cared for many people with severe mental illnesses in inpatient units. This study showed that they learned how to help their patients assess and work toward personal goals (goal functioning), assess functioning independent of the severity of symptoms of mental illness (holistic approach), and educate family members (family education). The finding that residents learned to assist their patients with goals in inpatient settings is encouraging, since patients are often involuntarily admitted and lengths of stay are brief.

The community psychiatry rotation imparted additional skills: the case residents learned even better how to assist clients with their goals (goal functioning) and assess functioning independent of the severity of symptoms of mental illness (holistic approach). Unlike the comparison group, the case residents learned how to identify and respect their clients' preferences (client preferences), a skill difficult to practice on inpatient units since patients are often there due to dangerous choices such as suicide. The case residents also learned how to assist their clients with applying newly learned practical skills (skills advocacy) which the comparison group did not learn. This is a central professional activity of a psychiatric rehabilitation day program, where the case residents rotated.

Finally, the case residents learned to provide services as a coordinated team (team value). In most PGY-2 rotations, the team divided the work by discipline and coordinated their efforts. In the community psychiatry rotation, the resident was responsible for the holistic care of the individual and relied on the team for input and feedback. This competency indicates that the case residents were more likely to include professionals from other agencies, elicit assistance from other team members, have time to coordinate services, and have regular meetings with the team.

The comparison group started the year with mid-range competency in involving families in the care of their clients, but by the end of the year this competency significantly declined. The initial competency may have been inflated since half of the residents based their answers on their PGY-1 experience on an adolescent inpatient unit, where families were more involved than on the adult inpatient units. By the end of the PGY-2 year when they reported involving families less, residents had only rotated in adult inpatient, psychiatric emergency room, or consultation psychiatry.

The community psychiatry rotation did not impart any competency in psychiatric rehabilitation. At baseline, the case residents and comparison residents scored low, as expected, but neither group improved during the course of the year. The low rehabilitation competency score indicates that residents believed that people with severe mental illness have "unrealistic and impractical" goals, and that clients cannot and do not benefit from rehabilitation services. While a 3-month rotation improved their abilities in recognizing and assessing goals, functioning, and preferences in a more holistic approach, their level of optimism for full functioning in the community remained low.

Most likely 3 months in a recovery-oriented community psychiatry setting is not enough time to develop this optimism. Residents may come to the rotation unaware that people with severe mental illness can benefit from psychiatric rehabilitation. They may not see any evidence to the contrary in 3 months because people with severe mental illness usually need extended periods of time to benefit from rehabilitation services. Psychiatric residents probably need more time in this setting to witness improvement in functioning and progress toward goals.

There are several limitations of this pilot study. First, the study enrolled a lower number of residents overall than intended, but trends and significant differences were shown. Future studies need to replicate these initial results with a larger sample and balanced comparisons. Second, there was a low response rate in the comparison group for the follow-up assessment. Third, there is selection bias in that the case residents chose the rotation; however, the difference is not due to interest in a career with severe mental illnesses since both groups reported similar interest at baseline. Fourth, the intervals for the follow-up assessments were shorter for the case residents (3 months) and longer for the comparison residents (12 months). This could have biased the results, but perhaps in favor of the comparison residents because they would have a longer period to learn the skills than the case residents.

Overall, PGY-2 psychiatric residents likely learn important skills for treating people with severe mental illnesses, whether or not they rotate through a community psychiatry rotation. The 3-month community psychiatry rotation, an ostensibly subspecialized rotation, enhances competencies which are valuable for general psychiatric education and mainstream clinical skills. However, it is not sufficient for full competency in providing care to people with severe and persistent mental illnesses. Residents need more than a 3-month rotation in their second year to appreciate the long-term benefits of psychiatric rehabilitation. It is hoped that the last 2 years of residency and public psychiatry fellowships confer full competency, but further research is needed.

At the time of submission, the authors reported no competing interests.