a longitudinal study of mental health consumer/survivor initiatives: part v–outcomes at 3-year...

A LONGITUDINAL STUDY OFMENTAL HEALTH CONSUMER/SURVIVOR INITIATIVES: PART V–OUTCOMES AT 3-YEARFOLLOW-UP

Geoffrey NelsonWilfrid Laurier University

Joanna Ochocka and Rich JanzenCentre for Research and Education in Human Services

John Trainor and Paula GoeringCentre for Addiction and Mental Health

Jonathan LomoteyWilfrid Laurier University

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The objective of this study was to evaluate the impacts of participation inmental health Consumer0Survivor Initiatives (CSIs), organizations run byand for people with mental illness. A nonequivalent comparison groupdesign was used to compare three groups of participants: (a) those whowere continually active in CSIs over a 36-month period (n � 25); (b)those who had been active in CSIs at 9- and 18-month follow-up periods,but who were no longer active at 36 months (n � 35); and (c) acomparison group of participants who were never active in CSIs(n � 42). Data were gathered at baseline, 9-, 18-, and 36-monthfollow-ups. The three groups were comparable at baseline on a wide rangeof demographic variables, self-reported psychiatric diagnosis, service use,and outcome measures. At 36 months, the continually active participants

The research was funded by the Canadian Institutes of Health Research and the Ontario Ministry of Healthand Long-term Care through the Ontario Mental Health Foundation. We would like to thank staff membersof the Centre for Research and Education in Human Services who comprised the research team for thisproject and assisted with data collection and analysis; members of the Ontario Peer Development Initiativeand the four Consumer0Survivor Initiatives who participated on the project steering committee and guidedthe conceptualization, implementation, interpretation, and dissemination of the research; and the staff ofthe Health Systems Research and Consulting Unit, Centre for Addiction and Mental Health, Toronto, fortheir work in coordinating all of the projects and for data processing.Correspondence to: Geoffrey Nelson, Department of Psychology, Wilfrid Laurier University, Waterloo, ONN2L 3C5, Canada. E-mail: [email protected]

A R T I C L E

JOURNAL OF COMMUNITY PSYCHOLOGY, Vol. 35, No. 5, 655–665 (2007)Published online in Wiley InterScience (www.interscience.wiley.com).© 2007 Wiley Periodicals, Inc. DOI: 10.1002/jcop.20171

scored significantly higher than the other two groups of participants oncommunity integration, quality of life (daily living activities), andinstrumental role involvement, and significantly lower on symptomdistress. No differences between the groups were found on other outcomemeasures. Improvements in 36-month outcomes for people with mentalillness who participated in CSIs suggest the potential value of these peersupport organizations. Further research is needed to determine thereplicability of these positive findings. © 2007 Wiley Periodicals, Inc.

In the mental health field, increasing attention is being devoted to peer support,self-help, and consumer-run organizations ~Solomon, 2004!. Consumer-run organiza-tions operate drop-ins, self-help groups, one-to-one peer support, social and recre-ational activities, artistic and cultural pursuits, advocacy and political action activities,and business ventures. While consumer-run organizations are innovative, researchregarding their effectiveness in promoting the mental health of their members is justbeginning to emerge ~Davidson et al., 1999; Mowbray & Tan, 1993; Solomon, 2004;Solomon & Draine, 2001!. Segal and Silverman ~2002! found that personal empower-ment of members of consumer-run organizations was positively related to the level oforganizational empowerment of these settings 6 months later, after controlling forbaseline ratings of personal empowerment and demographic variables. Trainor andcolleagues found reductions in rates of rehospitalization and use of other mental healthservices for those who participated in consumer-run organizations ~Trainor, Shepherd,Boydell, Leff, & Crawford, 1996, 1997; Trainor & Tremblay, 1992!. However, becausethese studies did not use control or comparison groups, the extent to which the positiveimpacts on members can be attributed to the consumer-run organizations is uncertain.

The purpose of this study is to examine the hypothesis that participants in consumer-run organizations will show improved outcomes at a 3-year follow-up relative to thosein a comparison group who are not active in such organizations, but who are equiv-alent in terms of other personal characteristics. To our knowledge, this is the firststudy of mental health consumer-run organizations with a comparison group with afollow-up of longer than 2 years.

METHODS

This study was one of several evaluations of different community mental health pro-grams in Ontario that used a common research approach ~Dewa et al., 2002!. Fourmental health Consumer0Survivor Initiatives ~CSIs! in southwestern Ontario, operatedentirely by and for people who have experienced mental illness and0or who have usedthe mental health system, participated in the research. ~For further information onthe study and its design, see Nelson, Ochocka, Janzen, & Trainor, 2006a & 2006b.!Consumer0Survivor Initiative, or CSI, is the language used to describe government-funded consumer-run organizations in Ontario. Members can participate in a numberof activities in CSIs ~e.g., committees, recreational events, drop-in, self-help groups!.

Design

A nonequivalent comparison group design was used to compare three groups ofparticipants: ~a! those who were continually active in CSIs over a 36-month period;

Journal of Community Psychology DOI 10.10020jcop

656 • Journal of Community Psychology, July 2007

~b! those who had been active in CSIs at 9- and 18-month follow-up periods, but whowere no longer active at 36 months; and ~c! a comparison group of participants whowere never active in CSIs. Data were collected through interviews with participants atbaseline ~BL!, 9-, 18-, and 36-month follow-ups. Prior to the BL interview, none of theparticipants had been active in a CSI, and all BL interviews were conducted within 3months of each new participant’s involvement with a CSI.

Continually active CSI participants were defined as those who participated 2 ormore hours in a CSI in the 6-month period before the 36-month interview and 4 ormore hours over the first 16 months of the study. The continually active CSI membersparticipated, on average, 10 hours per month over the 6-month period before the36-month interview and 12 hours per month over the first 16 months of the study.Active CSI participants for the 9- and 18-month follow-ups, but who were not active at36-months, were defined as those who participated more than 4 hours in a CSI overthe first 16 months of the study but less than 2 hours per month over the 6-monthperiod before the 36-month interview. This group of participants was involved, onaverage, 3 hours per month over the first 16 months of the study. The group of neveractive participants were those who participated less than 4 hours in a CSI during thefirst 16 months and less than 2 hours per month prior to the 36-month interview. Itis important to note that the continually active group not only participated over alonger period of time than the group that was active only at 9 and 18 months, but thatthey participated more frequently as well ~10 hours per month versus 3 hours permonth for the first 16 months of the study!.

Population, Recruitment, and Sampling

Participants were recruited through community agencies or hospitals. The inclusioncriteria required that participants had no prior participation in the CSI and thatthey met the Ontario Peer Development Initiative ~the provincial umbrella organi-zation for CSIs! definition of who could become a CSI member: “ ‘Consumer0survivors’ are defined as ‘people who have a mental health problem and0or peoplewho have used mental health services or programs’ ” ~Trainor et al., 1996!. Indi-viduals meeting these criteria were asked if they were interested in participatingin a research project, and they were provided with an information letter explain-ing the nature of the study and their rights as participants. The Research EthicsBoard of Wilfrid Laurier University approved this study, and all participants gavetheir signed, informed consent to participate in the research. All of the participantsmet the inclusion criteria, and all of the new members of the four CSIs consented toparticipate.

Recruitment and BL interviews began in April 1999 and ended in September2001. During the BL interview, interviewers discussed ways of keeping in touch withthe participant and asked for the participant’s consent to provide names of peoplewho could assist in contacting the person should he0she move. In the time betweenthe BL, 9-, 18-, and 36-month interviews, the interviewers did a variety of things tokeep in touch with participants ~e.g., sending a thank you card after each interviewand a birthday card and season’s greetings card once a year!. When a phone numberchanged or mail sent to the person was returned to sender, the interviewers began aprocess of tracking the participant through the contact information that they hadprovided.

Three-Year Follow-up • 657


Sample Attrition

A total of 161 participants completed the BL interview, 129 completed both BL and9-month interviews, 118 participants completed 18-month interviews, and 102 com-pleted the 36-month interview. Thus, the dropout rates were 19.9% at 9 months, 26.7%at 18 months, and 36.6% at 36 months. Most of those who dropped out of the study wereparticipants who could not be located for the final follow-up. We compared those whodiscontinued ~n � 59! with those who continued ~n � 102! on demographic, diagnostic,service use, and outcome variables from the BL interviews. There were only threesignificant differences between these two groups on 46 BL variables. Those whodropped out of the study had significantly lower levels of quality of life ~livingconditions!, t ~159! � 1.97, p � .05, and social support, t ~159! � 2.45, p � .05, anda greater proportion of those who dropped out did not have a primary therapist,x2 ~1!� 4.32, p � .05, compared to those who stayed in the study. Moreover, the attritionrates from 18-months to 36-months were not significantly different for those who wereactive in CSIs at 9 and 18 months ~15%! and those who were not active ~21%!. Thus, the3-year follow-up sample is generally comparable to the original sample.

Interviews

The majority of BL, 9-, 18-, and 36-month interviews were completed by consumer0survivor interviewers. The interviews were conducted in the participants’ homes, atthe CSIs, or at other convenient locations chosen by the participants. A structuredinterview was used to gather demographic, service utilization, and outcome data.Participants were provided with an honorarium of $15 for the BL, 9-, and 18-monthinterviews and $30 for the 36-month interview.

Measures

Demographic and diagnosis variables. Demographic information was gathered during allfour interviews.

Scales tapping outcome dimensions. Scales with established reliability and validity wereselected to examine outcomes.

1. Social support: Seven items from the Social Provisions Scale ~Cutrona & Rus-sell, 1987!, plus one additional item, were used to assess social support ~aranged from .79 to .83 for the different time periods!. Items are rated on a4-point scale from “strongly agree” to “strongly disagree.”

2. Community integration: Four items from the Meaningful Activity scale ~Maton,1990! and six additional items that tap community participation were used tomeasure community integration ~a ranged from .79 to .83!. Each item is ratedon a 5-point scale from “not at all” to “very often.”

3. Personal empowerment: Items from a self-esteem scale ~Rosenberg, 1965! wereused to tap personal empowerment. There are 10 items, which are rated ona 4-point scale from “strongly agree” to “strongly disagree” ~a ranged from .81to .86!.

4. Quality of life: An 11-item measure of subjective quality of life was used ~Leh-man, 1988!. Items are rated on a 7-point scale from “terrible” to “delighted.”



We used 3 subscales: Living Situation ~a ranged from .78 to .83!, Safety ~aranged from .64 to .78!, and Daily Activities ~a ranged from .69 to .78!.

5. Symptom distress: A scale was used to measure the intensity of participants’feelings of anxiety and depression during the past week ~a ranged from .89 to.93!. The 15 items, which are rated on a 5-point scale from “not at all” to“extremely,” were taken from the Symptom Checklist ~Nguyen, Attkisson, &Stegner, 1983!, with five additional items from the anxiety dimension of theSCL-90 ~Derogatis & Cleary, 1977!.

6. Service use: At all four interviews, participants were asked about a number ofdifferent mental health and social services that they had used in the previous9 months ~e.g., days of hospitalization, emergency room visits!.

7. Instrumental role involvement: At all four interviews, participants were asked ifthey had held a job ~for pay or as a volunteer! and whether or not they wereenrolled in education over the past 9 months. For each time period, we con-structed a measure of instrumental role involvement, which could range from0 ~no employment or educational involvement! to 1 ~either employed or involvedin education! to 2 ~both employed and involved in education!.

Statistical Analysis

We performed 3 � 4 mixed model analyses of variance on all of the outcome mea-sures, with group as the between-group factor and time ~BL, 9, 18, and 36 months! asthe within-group factor. Group by time interactions were used to determine if partici-pants who were continuously active in CSIs over 36 months showed greater improve-ment over time than those who were only active at 9 and 18 months and those whowere never active in CSIs. When the sphericity assumption for repeated measures datawas not met for time or group by time interactions, the Greenhouse-Geisser correc-tion factor was used, which entails the use of more conservative degrees of freedom totest the repeated measures. Significant effects were probed with planned, orthogonalcontrasts at each of the four time periods. The first contrast compared the groupactive at 9 and 18 months only and the never active group, while the second contrastcompared the continuously active group with the other two groups combined.

Because the groups are nonequivalent ~i.e., participants self-selected into CSIparticipation or no participation rather than being randomly assigned to one ofthe groups!, it is important to examine the preintervention differences to determinethe degree of nonequivalence. We found only one significant difference between thegroups on 40 variables at BL. Those in the group of participants who were active inCSIs only at 9 and 18 months were significantly younger than those in the other twogroups, F ~2, 99! � 3.29, p � .05. ~Note that a table comparing the three groups atbaseline on demographic variables, self-reported psychiatric diagnoses, and serviceutilization is available upon request from the first author. See Table 1 for a compar-ison of groups on the outcome variables at baseline!.

RESULTS

Social Support

There was a significant group by time interaction, F~6,279! � 2.65, p � .05, and asignificant effect for time, F~3,279!� 3.05, p � .05, on the Social Support measure. At



Table 1. Comparison of Three Groups of Participants on Outcome Measures at Baseline,9, 18, and 36 Months

Continuouslyactive

(n � 25)

Active only at9 and 18 months

(n � 35)Never active

(n � 42)

Outcome measure Time period Mean ~SD! Mean ~SD! Mean ~SD!

Social support BL 18.4 ~3.0! 17.6 ~3.9! 19.0 ~2.5!9 months 19.1 ~2.7! 17.3 ~4.2! 19.1 ~2.9!18 months 18.7 ~3.2! 19.3 ~3.7! 19.0 ~3.1!36 months 19.9 ~2.4! 18.1 ~3.6! 19.3 ~2.7!

Community integration BL 23.4 ~6.6! 21.9 ~7.3! 23.1 ~6.9!9 months 24.5 ~5.0! 22.0 ~6.1! 23.8 ~6.8!18 months 21.6 ~6.5! 21.1 ~6.4! 21.6 ~6.5!36 monthsa 24.9 ~6.1! 21.2 ~5.7! 21.1 ~7.5!

Personal empowerment BL 24.0 ~5.1! 22.8 ~6.0! 21.9 ~3.9!9 months 21.7 ~4.4! 22.7 ~5.9! 21.9 ~3.5!18 months 22.3 ~4.8! 21.6 ~5.4! 22.4 ~3.5!36 months 21.3 ~3.8! 22.1 ~5.2! 21.6 ~4.5!

Quality of life—Living conditions BL 4.8 ~1.4! 4.8 ~1.3! 5.2 ~1.4!9 months 5.3 ~1.5! 4.9 ~1.2! 5.4 ~1.5!18 months 5.4 ~1.2! 4.7 ~1.3! 5.1 ~1.3!36 months 5.1 ~1.6! 4.7 ~1.4! 5.1 ~1.3!

Quality of life—Safety BL 4.8 ~1.2! 4.6 ~1.3! 4.8 ~1.0!9 months 4.9 ~1.0! 4.8 ~1.0! 4.9 ~1.1!18 months 5.1 ~.9! 4.7 ~1.2! 4.8 ~1.2!36 months 5.0 ~.9! 4.8 ~1.2! 4.9 ~.9!

Quality of life—Daily activities BL 4.4 ~1.3! 4.4 ~1.2! 4.5 ~1.2!9 monthsa 5.2 ~1.1! 4.2 ~1.2! 4.8 ~1.1!18 months 4.8 ~1.3! 4.8 ~1.0! 4.5 ~1.0!36 monthsa 5.1 ~.9! 4.5 ~.9! 4.5 ~1.0!

Symptom distress BL 33.4 ~13.4! 38.0 ~11.3! 32.5 ~9.0!9 monthsa 27.5 ~10.5! 34.9 ~11.9! 33.3 ~10.8!18 months 32.6 ~13.8! 33.8 ~8.9! 33.5 ~10.2!36 monthsa 26.1 ~10.2! 34.0 ~10.8! 33.3 ~14.1!

Days of psychiatric hospitalization BL 7.9 ~20.4! 7.7 ~19.9! 3.9 ~12.6!9 months .2 ~.7! 2.7 ~10.4! 3.2 ~8.0!18 months 2.2 ~10.4! .9 ~4.3! 2.9 ~9.1!36 months .9 ~3.0! 3.4 ~12.2! 1.4 ~5.8!

Proportion who used emergency BL .39 ~.50! .25 ~.44! .28 ~.46!services for psychiatric issues 9 monthsa .04 ~.21! .19 ~.40! .23 ~.43!

18 months .26 ~.44! .16 ~.37! .23 ~.43!36 months .13 ~.34! .28 ~.46! .28 ~.46!

Instrumental role involvement BL 1.09 ~.43! .90 ~.56! .83 ~.62!in past 9 months 9 monthsa 1.31 ~.65! .86 ~.44! .69 ~.63!

18 monthsa 1.01 ~.53! .90 ~.62! .49 ~.56!36 monthsa 1.14 ~.56! .83 ~.54! .71 ~.67!

aThe continuously active group differed significantly at p � .05 from the other two groups combined at this time period.



the 9-month follow-up, the never active group scored significantly higher than thegroup active only at 9 and 18 months on this measure, t ~96!� 2.66, p � .01. However,the continuously active group did not differ significantly from the other two groupscombined at any of the time periods.

Community Integration

For the measure of Community Integration, there was not a significant group by timeinteraction, but there was a significant effect for time, F~2.6,220.3! � 3.13, p � .05.While the groups did not differ significantly from one another on the CommunityIntegration measure at BL, 9 or 18 months, continuously active participants scoredsignificantly higher than the other two groups of participants combined ~which didnot differ from one another! on this measure at 36 months, t~97! � 2.65, p � .01.

Personal Empowerment and Quality of Life Subscales

There were no significant effects for the following measures: Personal Empowerment,Quality of Life ~Living Conditions!, and Quality of Life ~Safety!. There was a signifi-cant group by time interaction, F~5.3,241.7! � 3.76, p � .002, and a significant effectfor time, F~2.6,241.7! � 3.04, p � .05, for Quality of Life ~Daily Living Activities!. Thegroups did not differ significantly at BL or 18 months, but the continuously activegroup scored significantly higher on this measure than the other two groups com-bined ~which did not differ significantly from one another! at 9 months, t ~95! � 2.86,p � .005, and 36-months, t ~99! � 2.87, p � .005.

Symptom Distress

For the measure of Symptom Distress, there was a significant group by time inter-action, F~6,279! � 2.15, p � .05, and a significant effect for time, F~3,279! � 3.18, p �.05. The groups did not differ significantly at BL or 18 months, but they did differsignificantly at 9 months, t ~93! � 2.52, p � .05, and 36 months, t ~99! � 2.19, p � .05,with the continuously active group showing significantly lower levels of SymptomDistress than the other two groups combined ~which did not differ significantly fromone another!.

Days of Psychiatric Hospitalization and Emergency RoomUtilization

While there was no significant group by time interaction for days of hospitalization forpsychiatric problems, there was a significant effect for time, F~2.0,183.8! � 3.93, p �.05, with all groups showing a significant reduction in days of hospitalization overtime. There was not a significant group by time interaction for use of emergencyservices, but the groups did differ significantly at 9 months, t ~96!� 2.67, p � .05, witha significantly lower proportion of the continuously active group using emergencyservices than the other two groups combined ~which did not differ significantly fromone another!.



Instrumental Role Involvement

For the measure of instrumental role involvement, there was an effect approachingsignificance for the group by time interaction, F~6,249! � 1.80, p � .10, and for time,F~3,249! � 2.35, p � .07. While the groups did not differ significantly from oneanother at BL, a significantly greater proportion of the continuously active group wasworking or participating in education at 9 months, t ~93! � 3.85, p � .001, 18 months,t ~94!� 2.61, p � .01, and 36 months, t ~98!� 2.47, p � .05, than the other two groupscombined ~which did not differ significantly from one another!.

DISCUSSION

At the 3-year follow-up, those who were continuously active in a CSI scored signifi-cantly higher on a measure of community integration than the nonactive group. Thisfinding is consistent with a previous qualitative study in which members of CSIs inOntario reported enhanced community integration ~Trainor et al., 1997!. The CSIsbecame a springboard for participation in other community settings. There was also asignificant impact of continuous participation in CSIs at the 3-year follow-up on thequality of life measure related to daily activities. The items on this scale focus onsatisfaction with social and recreational activities, which are a main focus of the CSIsin this study. Similarly, we found a significant reduction in symptom distress forparticipants who were continually active in CSIs relative to those who were never activeor not active at the 36-month follow-up. This finding is consistent with previousresearch on mental health self-help groups ~Moos, Schaefer, Andrassy, & Moos, 2001;Powell, Yeaton, Hill, & Silk, 2001!. Finally, we found that continuous participation inCSIs was related to involvement in employment and educational activities at 3 years.

It is interesting that that two of the positive outcomes ~quality of life—daily activ-ities and symptom distress! for participants continuously active in CSIs showed a cubicpattern. That is, there was a significant improvement on these two outcomes at 9 and36 months; but, at 18 months, the groups did not differ significantly from one another.The continuously active group regressed to a level comparable to the never activegroup and the group of participants who were active only at 9 and 18 months. Asimilar trend was noted for the social support measure. While it is not clear why therewas a regression to baseline levels at the 18-month follow-up, these findings indicatethat improvement in the context of consumer-run organizations is not a linear pro-cess. This is consistent with the emerging literature on recovery, which has empha-sized that the recovery process includes setbacks, as well progress ~Ochocka, Nelson, &Janzen, 2005!.

Another interesting finding from this research is that only the group that partici-pated continuously and intensively in CSIs showed benefits in terms of communityintegration, quality of life ~daily activities!, symptom distress, and employment0education. The continuously active group participated 10–12 hours per month duringthe first 16 months of the study and the last 6 months of the study, while the groupthat was active only at 9 and 18 months participated only 3 hours per month duringthe first 16 months of the study. These findings are consistent with what has beencalled a “dose-response” relationship in intervention research. Evaluation research ofinterventions in other domains, such as preschool intervention programs ~Nelson,Westhues, & MacLeod, 2003!, has shown that the length and intensity of interventionsis associated with better outcomes at follow-up periods.



Several outcomes were not affected by participation in CSIs. Because these orga-nizations do not directly focus on changing an individual’s housing or the safety oftheir living situation, it is not surprising that participation was not related to quality oflife related to housing and safety. On the other hand, the lack of impact on empow-erment is puzzling, as empowerment is one of the goals of CSIs. Perhaps the globalmeasure of self-esteem that we used was not sensitive to changes in perceptions ofcontrol. Like other studies ~Edmunson, Bedell, & Gordon, 1984; Kennedy, 1989; Trainoret al., 1997; Trainor & Tremblay, 1992!, we did find a significant reduction in days ofpsychiatric hospitalization for those who participated in CSIs. However, there was asimilar reduction in days of hospitalization for those in the comparison group. Becauseprevious research has not used comparison groups, it may be that the observed reduc-tion reflects regression to the mean rather than impact of a self-help intervention.There was an impact on emergency room use, but only at the 9-month follow-up.

It is important to keep in mind that the vast majority of participants in the studywere involved in other mental health services. Most CSI members had a psychiatristand a primary therapist and participated in other community mental health programsor community organizations. Thus, the positive impacts may not be due exclusively tothe CSIs but rather to the “value-added” by CSIs to other more mainstream servicesthat they used.

CONCLUSIONS

The findings of this research suggest that CSIs should be more of a priority in mentalhealth policy. In 1993, the government of Ontario adopted a policy framework pro-posed by the Canadian Mental Health Association ~Trainor, Pomeroy, & Pape, 1999!,in which consumer self-help is one of the key components of a reformed mentalhealth system. This framework asserts that government needs to invest in the capaci-ties of consumers to help themselves through funding CSIs and to actively engageconsumers in planning processes for mental health reform.

We conclude by noting the strengths and limitations of the study. Few studies ofself-help in mental health have used longitudinal designs with a comparison group,and there are no studies of self-help in mental health, of which we are aware, thathave followed up participants for more than 2 years. Moreover, there have been evenfewer studies of consumer-run organizations in mental health ~Mowbray & Tan, 1993;Segal & Silverman, 2002; Trainor et al., 1996, 1997; Trainor & Tremblay, 1992!. Wewere also able to compare groups of participants who had participated for differentlengths and amounts of time. Thus, this study represents a methodological advanceover previous research on consumer-run organizations.

Nevertheless, this study also has several methodological limitations. First, the useof the nonequivalent comparison group design does not rule out the possibility thata selection factor accounted for the improved outcomes, even though the groups wereequivalent on several measures at baseline. Perhaps those who are motivated to joinand participate in a CSI are more likely to improve than those who are not interestedin participating in a CSI. Second, the dropout rate from baseline to 3-years of nearly37% is high, although we did find few differences between those who continued andthose who discontinued participation. Third, the study used a small, nonrepresenta-tive sample of CSIs in Ontario, thus limiting the generalizability of the findings.Fourth, there is the problem of conducting multiple significance tests, which caninflate the number of significant effects that may be found by chance. Fifth, the sites



did vary somewhat in the types of programs that they offered, but our sample sizes foreach site were not large enough to permit an examination of site effects. In sum, whilethe findings of positive outcomes for members of CSIs at 3-year follow-up suggest thepromise of these types of settings in promoting recovery, there is a need for furthercontrolled, longitudinal research to determine the replicability of the findings.

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a longitudinal study of mental health consumer/survivor initiatives: part v–outcomes at 3-year...

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