2002 - Focussing On Quality Of Life In Treatment

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Focussing on quality of life in treaEnent R. MCCABE& S.PzuEBE Unn Jor Social E; Cannrni,t London, UK

Psychiaot, Bars and The Landnn Schoal oJMedic;4e' Q een Mart'

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Thete re ;idespadd eau' lor ttu inplznentuion ol o"t@es manasmdt in f,ental l9ahh seFtices,@hich inlabe: turtinelt ase$1ns pati;4, outun;, ,a anallv ,he efle6hen6s oJteatnenL me emphri in out@46 hanacenent i, on assrsa'in9 olkon. indiridut aata on thi tael of etoups and etues and leedifls rhe raula bdch ro cof,milnote$, cli'icidns and nandsers ta inJaml thei d.rFia^ i, me"tut heahh t.tui. qearch i qbtit! ai W' uhich f daetapmtt ini funltins. The nost inportan aubone cidia, m snie akorte'cenne?ie.e'olautane:tudnasemenLIflvtetuJeaunti6'the4oreplaaloihPknentthenalnco4?onenoJauxon'! xalid data 811 anlt Htueer' cane 6'essme,t rceunre cliniciatu ta rottinelt 6te$ PaLient outme gdtient hxeL Concufrent be cor\ced ij it t uonhuhik Jar .tiniciatu ai.1 parienB at rhe tloet an tuhich i i rcIe.ed, i.e. the ihditidtat as*snen ina Jeedtacp.ol ouxone data 'a th. clinitbn and pari."t sa tiat Lk! iafomarion .an be 6ett b infom teatuenr d.ti,ii6 milh|naken@thfuhile'AEufu?ea"fluhi-centercndomizedconful].d''iali.!nentJ!'nderua!bkn'heelJc6ofsuchoi et[x patiehts, .aeus an rheit ,4uaLitt oJlife, n9n.nt ininennon in the *eatnent aJzsr;hotu iLtu$. K,yuothds tifi slsenatiaut bt sattsjlction and ued, Jot ad,tinana diferc"t c' otet | !er. It is ht"poih$ized 'hd' the intetue,rbn uil im?tNe Panent a,tcam. d'rinot 'eah a basis p,oe6s in tudnne"t 6 pns*s-aad tach oJ lar Jtths dnusi"" abou*eins "rpbi Jt iloipn"e 'u a bet'ef th; ;nt;tue;tior is eiec'be, n is hJporhesized rhdt the efect uiu be nedidtud trr norc a@ftpna| tuam,nt dec^ions aIdtor pdtiehl n, iilotlment nd! als,o p.6pective hteoctba patunt h rhe therapd.i : ldeiliate ih*apat;e reIorionntp. Fu6nns o4 rh. la't -";e"^-; " sd? a Echvcat em, wtich codd be"eilt fton Jurthq '?*ifnntu otu"-^ .r;iut, a""J",-^.tne. trtdtftent Pt.aes in ndtal health eat deaelopnen. it Ddet ta etpbn is Paehtial Jar iflPtutils

Aims ofmental

health care

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aims ofmental health care seem to chanse over rime (Schmiedebach et a1., 2000) wilh dif€rent emphas€s in difierent periods (e.g. intemmenr, human rignis, containins risk). AIL\ough therc are n o L n t v e r . a l l ys g r e e dd e f i n r D u n so f w h a r c o n s L i r u r e s mental health care (Priebe, 2000), few would disag r e e $ . r t l e i d e a l o l a - l lm o d e m h e a l L h c a t ei ' ! o enabL" individuals ro maximize their qualiry of life (Knhan & Angerme\e'. logoi Awad & Vorugdnd. 2000). Consistenlwirh this ideal, rhe goals of memal heaithcare are no longer restricled to reducrng rehospitalization aDd sJ'rnptoms but now include e n n a n c i n sa n i n d i v i d u a l ' b r o a d e r r o l e t u n c b o m ' ) g and social integration (hhman, 1983).

Outcomes managereDt Enhancing quality oflife is cendal to a new approach in he3lth cale called ourcomes managemen!' defined as a 'techrology of patient expenence designed to help patients, paye6 and ploviders make ratronal medical care relaied choices bssed on better insight into the effect of these choices on the patrent's o_" 1 1.-J F.u. -. r..1. I:.e TL. . -

characterize outcomes management greater use of sGndsrds and g]]idelinesj routine assessment of patienr tulctioning at appropriate trme inleialsj pooliog outcom€ data on a massrve scalej and d j s , e m i n a u o no f d e s < r e . u t ! . r o r e t e v a n rd e c i s i o n . makers- The ultimate aim ofoutcomes management rs ro improve clinr-rl pcrforarance and paueaL ourcomes {Smith dt 41, r997).

Outcomes management process therapeutic

iq the indiwidual

Alfiough widely called fori ourcomes managemenr has nor been widely implemenied. The reasons for *1is include lack of a$eement about \r'hat 1o assess, rnd olg'n'3lack of ,icendres dotrat resistarce ro change (Maik, 1998; Harriso! & Eaton, 1999). Recendy' L\ere have been iniriatives ro r m p l e m € n to u r c o m em e " s u e m e n r i n r o u o n e " e t d n g in various countries. In Ensland, the Natjonll Health Senice is piaming to implement some of ihe techdques of ourcome management. Although the assessmentmeasues have noryel been decided upon, Lhereis the expecta.ion thai every p:fienl shou]d have L\eir morbidiq, qualitl of lfe and lre:rlnlenr saiisfac-:L:"::\ . : el . . \..1:r '-:.i : r"

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r,hroughout the counul. The emphasis in outcomes managemenris on analysingdata on the level of seffices and $oups. Asking clinicians to regulariy assess ourcome is likel,\'to be perceived as just anothtrprece of time coosuming pape$ork if the results are only fed back on a serice ]evel.Valid daia will onlv be collected if tiere is some benefit for patients and cljnicians on ihe level at whjch the dat3 is collected, i.e. the jndividual patient lcvel ff the clidcian and patient can use the informarion rhat is roudnely collecied in s meadngtul wa,vin the iherapeutrc process, roudne outcomes assessment-and hence outcomes management-is more likely to happer' The dominant approach to measuremeDt in outcomes managemeDt is pre-post measuement of oulcome, which stems from rhe classic pre-post design in experimenral lese3rch (Brill e. al, 1995) This approach is in line wift the emphasis on pooling outcome data on a massive scale so that managers and ciinicians can evaluatet\e qualitv and effectirenessofa given treatmeDt selvice or organizadon (e g. Srnith er al, 1997j Salvador-Ca.Ulla, 1999; Stade, in press). However, routin€ly assessing treatmeni ourcome lends itself well to assessirg the impact of L r e a L m e niln i n d r $ d u a l I r e a l m e n t c a < e s( e g B r i l l et oL, 1995t Marks, l9S8; Priebe, l99gj Slade, in press). Brill et al. (1995) cali this the concurrent approach to outcomes managemetrt, !\'hereb)' informadon is sa6ered at multiple rime points fo. an ongoing evaluarion of treatmen.. Concurent outcomes management mayhate some advantages over pre-post outcomes managemert Firstly, the concurent approach (while alloqns a pre-post compansoD) canbe usedto identifv lhe time cours€ of improvement (i.e when gains occuned duing r,\e coursc of rhe intenention), which is pafticularly usetul in iime'limited interaentions (Bnl1 et al., 1995;. Marks, 1998; Lambert et al, 2001). Secondly, it ma-v have mole ecological validity in evaluaringthe etrectivenessoftreamrent than pre-post outcooe assessmentinsrudiesofmodei services(Brili et al., 1995: Piebe, 1999). In othe! words, dle findings maybe nore applicable ro the'real world'as 'research$ortd' (Harrison & Eaton, opposed to the 1999i Slade, in press) and consequentlv more generaljzable.For example, ithas been suggestedrhar c r . e m i r n a g e m e n rt a r b e l e . s . u 5 t a i n a b i ei n r o u d n e s e l r n g , J r a n u n d e r r d e d rc o n d i r i o n . . b u t o n g o i n g evaluadon in routrne practice is lequired to identifu how it tun€tions under the pressures of less ideal conditions aDd how ir can be susiained in lons-renn uajectones ofcare (Br.:rgess& Pirkis, r999).

lvhat outcomes should be assessed? .rtr:.!r:'sar:-1S: . . . . . . .i : . : r3rron h,r'e b.e. highLigi,red ismilh .: al. i997j I h r k s , 1 9 9 3 ; S a l v a . l o r - C ! r u l l a 1, 9 9 9 i S l a d e . ; ! 1 ,

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1999). Deciding on the criteria for assessinssuccessrs not straighdoNard. As Perkins (2001) nores, the list olinteresred parties is porentially long ilom poliricians and pressure groups ro patients and carcrs. Each par.y ma,v have difierem vie*x about the goals of trearment and, hence, the relevance aDd value of diflerent outcomes. \trhat is more, ihere often exist difierent pelspectiveswithin any of these sroups. For example, difierent professional gIoups do not necessanlv agree about q'har deatment should be provided and x'hat outcomes are desirabie.The outcomes to be assessed will also depend on *le disorde. being ueated BecauseofL\e pervasivenessofse.ious mental iilness, people wirh complex mental health problems fte quently require suppon in diffeftm domains of their life, e.g. managing symptoms, housing, 6nances,practical skills and rciatioaships. Hencermuiople outcome domains may need to be assessed. 'the ln the context of outcomes managemen! centrepiece and uni&ing incEedieDt of outcomes management is dle tracking and measuJement of tunction and well-being or quality oflife' (Ellwood, 1988). Thele is also a coDsensusin mental health senices research that qualitj of life is the mosr important ourcome critedon (Slade, in Press) While rhere is some disagreement about what qualitv of life is (e.g. KilliJn & Angemel,er, 1999i Lauei, 1999; H e r m a n , 2 0 0 0 . / . I J ) e r er s a $ e e m e n r r h a L i r t a c o m p l e x , o n s r r u c t e n , o m p a ( s r n gm . n ) d o m a i t u . a r least health, social relations, family relations, ork and leisule (v3n Nieuwe.huizen ,' dl, 1997) There is also debate about the relative importance of subjecrive and objective iodices ofquali4 ofLife (e s Warne!, 1999), with some expressingconcem about the reliability of subjective assessmentsofi'ellbeing and sheder rbey can be treated as objectivelv as direct assessmenls of parholos'J @1lwood, 1988). A*'ad & Vorusanti (2000) suggest that self-ratilgs about deatmert ouicomes by people with schizophrenia have been liewed suspiciously because L\eir cognitive capacity may be compromised However, cumulative fiDdings indjcate that subjective quahtv of life ratilgs are reliable and coEelate to some ertem s'irh clinicians' ratiDgs ryoruganE .t al, 1998). N{oreover, subjective quality oflife indicators in specific life domains are much bener predicrors of overall wellbeing compaled wit\ obiective indicaton in the same life domains (Lehman, 1983).

Clinician-patient

co[aboration

in treatmett

l g r e e m e n to n { h a r c o - { i P a L e n ra n d p r o f e " s i o n a a given lhet enhancing imponant rutes qualiiy oflife is quali$ of life is the ovelarching goal oftrea.inent A n u n o e r o f s t ' r d i e s( S h e p h e r de r d l , 1 9 9 4 i M , ! e n . rr Jl., :!)ll I I hI. 3r:il.f.l d:ini : j ' r i r- r - : : : : I . t . : r i r i s f f q u r l i o f l i i . t - \ ! ] l i i e n i s a t l Cm i . r a l h . r l ' . h t.ofession3ls. In g.ner3l, !auents' priL'ritresrelare ro he,rlfi ard so!i!llif. (work, housing, noance,lersure

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rourine meetinss. Quaii$ oflife (mental and phvsical Although mental activiries, jol oflife, relarionships) h e J l r l r ,J c c o f f m o d a L . o nr.. b r t ! 3 r i o n . I c b L r e r c E r i ab*n'e ^lill' h e a l L hp r o f e q n o l s l , r r ' o p n o r i d r e l h e ties, friendships, relauonship with famil,!/partner' ' i d e - e f i e c r sa l o n s r e , s r e ' a l e dd e 6 c i ! sa n d m e o i ' a d o n persotal safetv), ire3tment satisfactioD (pracrical :upDoR' vrI]]1rn< at arbbiliq of s.rilable Drofessional help, psycholosical help and medicarion) and needs er al ' 1995; dlreatment and moDtoring (Shepherd for care ftom lhe p atient's perspecuve!dl1 be system6 e r e : ' c o n s ' d e r r h l eo t e r _ A n s e r r n c \ e te r 4 1 . l 0 0 I aticallJ'assessedevery 2 monrhs. This \ii1lbe done bv emphasizing tjp"*i.t' Uo.r pru.nt',nd profe"'ionals rhe ke\'worker and patient together when t}Iev meer' work. relarionships and independence' There miehr be coDcem that social desiFbilir" mll evaiuate The UK Depaflment ofHeal$ intends to in{uence these ratings, i e that lhe kel'workers' '"g"i*, *" uspiradons and experience of o"ui*.lt. pre'en'e D r $ e n c e h r l l l e a d L oh i s h e r r c u n g s L h d nt b e of HealL\, 199r-) 'nd rhe ;." ,.r""t"' fl.putt-""t H ^ u e v e r , Ersll) r e s e a r c h e r of an ;ndependea' ot Health N a r ' . " a r S e r - i e r r a m e qo r k r D e p a n m e n r to serdngs in routine aEilable lesealchers are nor bv Lhe loou s.are5 $aI seflices should be Ied & Kaiser secondlv, outcomes. assess reatment glven inrerc"t, of trsuscrs This is hardl) 'ulpnssg of de €trecr a limited onlv Pneb€ (1999) found seluce Lhar a collaborauve approach in healln iniefliewer inte ie\tee relauonship on subjecrive A significant orovision leaas to bette! outcomes ouahN of life rnings rhal a b o d ! o l r e ' e a r c b r n p r i m a r ac a r eh a s i n d r c a t e d A -rucial I'sue for L\e \"hdrq of fie inreryention q h i c h p a u e n t f a c i l i ! d r e s o " L j c n t - c e n L r e da P p r o a c h wi1l be ilLat the infomation assessedis understandsp r f l r c i p a t i o na n d a c t i v e l vs e e k s$ e p a D e n Ls p e r s p e c pat:ent" b l e a n d m e a n i n g t u lf o r b o t h c l L n i c r a nas n o wllh nve in $e uealflent tnteraclion i' as"ocra'ed idealll managemeat ouicomes Accordins to Ellwood, (Slewaft' increased saiisfacdon and compliance '"n""isrs of a com-on parient-understood langlage less 1 9 8 4 ; B e n a k i s " d . , 1 9 9 1 ;R o l e r a ' a / ' 1 9 9 7 ) ' ouG of health outcom€s' (1988' p 1551) Rourine fewer and 200l) "vmptom b.raen @inle er ol, a feasiblei and valid bot.\ be come measures should misunderstandings wirh unftvourable consequ€nces relevant' simple, bdef, be feasible measure should (Bri$en et al, 2000) acceDtable and v3luable to its useis (Slade 4 ar' in studies These frndings are coosistent vith of ls96). Each of the quesdons concernins qualitl validiw menlal health care identifving the predicdve be to caie for needs and life, ireatment satisfaction m of paden!'s subiecdve assessmentsof treatment assessedin the MECCA studv are bnef, simple and Gru]'ren & Studies bv Priebe ."l"oo. to o.'."o-. 199 5 j relevant to users' concems (cf Shepherd €t al ' thar (1999) found Broker & ?riebe and rtggta) Anqemere- ercl. 200l Lelhoteral 200l rrea' schizophreoia patient's sadsfircdon wirh rheit i h e n a t r : r eo f k e $ o : k n s i n t o l v e ' c h n i c i " n sm e e r predrcted ome ment in long-rerm cotmunity care jn a varie$ of setiings' including ins fieir patients penod' \penr in ho'piI3l ove-a 21 mon$ [ol]^w-un o$ce or wiL}i thi padenti home, r-\e mental health team Ar''ong pari.nrs siLh depre'"ion 5ati5faclrcn across outcoFe assessing the hospiul Regularly at dl= re.lrminr preoicred self-rated slmptomt 2dvances Recenr practicable ihese settings must be cnare. p.iU. t Crutre!5 loo5b Simil'r indrncs technoloe] mean than paPer and i" i"r.'*,.;." q'ith consr'rct' an overlapping have been teponed Dencil rneasures can be replaced bv computenzeo relationi.e. the therafeuric relatiorship A Positive end' assessmentsusing mobile technologies To this shiD *'ith one's primarv clinician is cons$renu'v so developed being cuflentlris a software application & foud to predict a betrer outcome (ct Mccabe mobile a completedusing can be rlat tle assessment in Pn.te. "usmined for pubL'atron ' rerecred alow the hand-held compurer' The aPplicatiof, will i n h o s p i L a l a o d i n d r c e ,s u c h d " s ! ' r n p r o m a l oo g l , u n e kela!orker and/or patient by L\e ratings ro be entered Rvan oualit\r of iife (Frank & Gundetson, 1990; will be into a database The results ofthe assessment Solomon 1995; it "t., $gq; Neale & Rosenhecls to rne presented and aPplicadon processed by rhe ", ,t.. too:l Krupnick.I al. l99o Ga\ton eI c!' then' and patieDt there ker"itorker and ' l o q S i s v e n , s o n& H a n s s o n .l o o o i T a t t J n & T a r r i e r . along the quatit) of life and satisfactioo scoresr 2000). cunenr in the mted care, with needs for addidonal n a a n d $ e o r e v i o u : a ' s e , s m e n tM l l b e p r e s e n t e d $ill h'ghlighl E a p t u c a i c o l o u rd r , p l a t T h e f e e d b a c k The MECCA study wi$ life dissatisfacdon ZO'"n""g" "*. time; &) fol (c) needs and oi reatment ".p..t" io-ui".-r"a of Assessingthe p:tienfs perspecdveon rheir qualit-v discussion explicit prompt mav addir1onalcare :fhis will be life, ueatment sarisfactionand needs for care to De about the reasons for change and rhe a'ion managemenL at the heaft of a concurent outcomes (and nos' laken Informarion about raungs over lime This lnterleilron to be tesred in the MECCA srud-v circumsrances) person's ro I it'",' .r',r"g. accordrng n'rl':lcenrre clustei ranciomrzeo .ru.\'is a Eur.fe '.ridu.!'l ::r r'rcrli::r: C r o m n g : n ' rn Granr'Ja :cr::r1i:c triaj ':'! p r , - . - l r t s st r.r h c i r o i p ; L ' g r * s . ! r ! r c l i n l ' : : l r ' rill li I.",.r' \l3unheiD anc Zunlh r -lr:.,., 'r:rrg'J]' lncre r'' "",srn or,,cuor. ""gi': L" rn.-tuiing ieeding rite i'jor." ."g'r"'L-u "'."*ing our'oDl' aDd atrd'or runber of apprcpnate trerlmeni de'iions iner durlng r:slrLrs back ro rhe clinicisn rDo pad'r:

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improling '.\e therapeutic relar;onship lt is conceivable L\ar specilic inte.'entions couldbe implemented io jmprove quality oflif€ rarings (Pdebe, l9S9) The inrelaentions might b€ practical ro change a penon's objeciive circimstances (e.g. housins) o! Psy€hotosical ro change a person's subjecdve vie\a'oftheir !l€ siruation (e.g. cogdtiv€ behaliour therapv)- The M€CCA study will test tbe hlpor,\esis rhat such an inrenenrun $ill-akin ro in'enenDonsin s!ffreCi. ps)choLhcrrpl-.umuid e and promote a pos'ove therapeutic dialogle and lead to a more favourable outcome. Hence, impiovementin outcoDe would be mediJred Lhrorgh more app-opiare theraoeu!ic inr€rventions as decided by rhe clinician and pauent or abener de.apeutic relationship in line wlth a pa!tnership model ofcare or both

From outcome to process The idei ofassessingoutcome and feeding de rcsults back on an ongoing basis duing treaL'nent sbifts the focls Aom trealment outcome to the processofcare It has beeD noted (Priebe, 2000j Brrgha & Lindsan has been 2001) rhat the processofcare in psyc}11atlf, neglecred in favour of investigadng the structural aspec'rs of care. The laner approach has involved arremp6 to lint the structue ofselvices lo individual parient ourcome {iLhout considering r}}e mediatrng etrecrsof clinical practice. As all menlal healthcare js delivered Lhiough the clinician patient reladonship (Mccuirc er al., 2001), jt is not suprising that ihis is an impoltant factor mediaung outcome. Ifrouii.e ourcomes management does make a difference and improve outcome on an individual paoent levcl, it will be necessaryto understand how it is done in pracdce aDd *'har makes it etrecdve As 'outcomes managemenCis a technical tenT}. ir srands, AlLhougl itsounds relatively straightfos'ed, t}lerc is limited specilicadon of holv it should be done and incorporated into individual care processes.In order ro jdentifu how it is implemented and made effective in eve.r-daypractice, qualitative sludies of clinicianpauent interacrions will be .equired. A qualiBtive rechnique (i.e. conversation analysis) for analysins interactions between padents and healthcate professionals is receiving increased attention (cf. Drew er al, 2001j Madill er aa, 2001). Thjs method analysess'hatpeople do ral\er than whar fi€y saythey do. As Dreq'€' al. (2001) note, conversation anal)'sishas L\e potemial to make expiicit how professioMls and patlenis conrmunicate and rhe intenctional .o.se_ quences of adoptins one lvaf of doing things rarher rhan another. Conversadon snal\"tic resealch has , h o $ r ' n a r h o ( d u c t o r . d e . q - L h er t r l k h . . c e n r i .rin:eq:er.es irr \!hat l3!ie.ts go on to sa! and do p:'-'j.5srinrl) !.rn Lr: C..r.. .!: ..l.ri.! ai.l iri . . n . i i r i n i s lir nfrt ('.less .riri.- Iii .,rniiauni.arl: Peliik-ti;i, 199Si Heritlge & p alienr F arricrpaiifn le.-q o u i c o m .s nin:gement Sd';.rs. I9r9) If ro!'jn.

leads ro better outcomesJ this methoColog] could begln ro specii' how outcomes management rs done -r.c: n p r a c u c . a n d h o $ f i e p r t i e r L i n ' r L l i n i c r " ni n more successtullyundei these condidons

Outcomes management is widely called for but there are many obstacles to its implementaton. Rouune outcome assessments'ill only happen if it is worth_ shile for the clinician and lhe patient at lhe level 3t {hich nis ro be conducted, i.e. the individual patieni level. ,{ triat to tesr the routine assessmentof quality of life using a hand-held mobil€ computer which feeds rhe data back dlele and then to the clinic1an and patient is cuEently underuay. lt is hoped that rhe routinely coilected data can be made usefin for r h e c l r n i c r a na n d p a D e n rb t i n f o m r n g o n ; o i n g L r e a I ment activities. If roudDe outcomes managemeni does lead to betterpatient ourcomes, researchon the interacrional processes wil be required to specii' hos' it can be made etrective in cliDical practice and to make recommendations about how it catr be successtullyimplemented.

A,\cEp$EYr& M.C., HorzNGE& A.i i:ll]jA-, R. & MarscHNG!& H. (2001). Qlality of life-as denDedbv schizophrenicparieDF and prychiar.isls lnudanonol Satdal al Sacial PrJ,chiotD,,17, 3442. A r \ D , A . C . E ! o P U c $ 1 . . L ' J . P . 2 0 0 0. l . ' e f l e n t i o a ot issuesrelaredto tle assessmem lesearcltin psychosis: quariq of ljfe. S.iEorile"u Buletin, 2 6, 557-564 BERfr,rds,D.. Rorr\ D. & PLrrN.c.v,S.M. 0991) The r e . r r i o n , h , p up fn r .i - : e r e d r c r ri n t e M e s ' D e r op a t i e n l s^ris't^ario^JoumalaJFadil:l /|' de.ie,32,115 lal B R n - , P . l . , L r . , r ,J D a G k r s o u C . R l o o r T i n I is everylhing: lre-posr ve. BeharioralHeaLhcarcTonoftM, 4, 16-77 C.A, BAxnER,N BruTrEN,N_-,SrE\ENsoN,F.A., BA-RRY, :n pre& B R - A r i L r .C, . P . 2 0 0 0 ' . M r s L . d e ^ r a n d tcr' scnbingdecisionsin gene.alpractice:quahanvesludl British MedicdlJoumdl' 32a, ra+lA8 F. (2001) Qualio of nenml BRUGtr1,T.S. & LD{DSAY, healih care,6.om processro afiributableou(omes ID: M. TANsEts & G. THoRNlcRoFr @ds), Mentul teahh oa&o-dn,drrla. Glasgow:Gaskell. BuRGEss,P & PFxrs, J. (1999). The cnency of.ase nranagemen!:benefiN and costs- Crnent Ophion it I 2, \95-),99. PslchiatDr, ol llxArrH (1997). The ne@NHS: nodem, DEPARRTMTN'| d'?,'ddOle.l]Jndon: DeparirLentof Heald. D!pARrMEIJ\ToF HEALTH (1999). The ndtionotstuQ t'.ntuarh jot mentathedtth-kndon: Delaftmenr of Health. DnEv, P., Cll-\r-ro^. J & CorrNs. S. 12001).Conrersation anlhsis: a melbod for res€a..h lnio rnlel.trnns ' ' ' ; :a:i..ir:r,,ri. l. i! ?{r. EnLL{!.rr, 1' \l i.l!.1s.. Shriiu.i i.r!re ' rl.irr.' mhigemcri. A tecinoloEl ol latient e+cncn.: rir. \'.1! E1!!ld,1d Jonm.1.J,t It dlin,., JlE, 1510 155D.

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230

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life of clients wirh severe$ett,l ilLless: a review of h , L a n e n F . | J { a , a r . R .! o b J t a a a l a u a a l 2 0 , ) ) 4 1 R.J., AvAn, A G. & voRUGANrr.L.N.P., HTSLEGRA!€J s " . ^ L A N\,' 1 . \ . \ 1 9 o 8 . Q u a h r ]o i l , f e m e r ' r e m e n t i a schizophrenia:reconcililg rhe quesrfor srbjectivity \tith

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