Disability & Rehabilitation, 2012; 34(18): 1575–1584
© 2012 Informa UK, Ltd.
ISSN 0963-8288 print/ISSN 1464-5165 online
DOI: 10.3109/09638288.2011.650315
REHABILITATION IN PRACTICE
Community involvement, planning and coping skills: pilot outcomes of a
recreational-therapy intervention for adults with schizophrenia
Gretchen Snethen1, Bryan P. McCormick2 & Marieke Van Puymbroeck2
1
Department of Rehabilitation Sciences, Temple University, Philadelphia, PA, USA and 2Department of Recreation,
Park and Tourism Studies, Indiana University, Bloomington, IN, USA
Disabil Rehabil Downloaded from informahealthcare.com by University of Queensland on 09/20/13
Purpose: The Independence through Community Access and
Navigation (I-CAN) intervention was developed to increase
community participation in adults with schizophrenia spectrum
disorders (SSD) through identification of interest-based
recreation activities and supported participation. Method:
Ten individuals consented to participate in a 10-week pilot
intervention. Eight individuals participated in the intervention,
For personal use only.
during which time they worked with a recreational therapist
to identify interest-based recreation activities, develop
participation goals and coparticipate with the recreational
therapist. At the end of the intervention, seven participants
were involved in a semistructured interview to understand
their perceptions of the intervention, including its outcomes
and effectiveness. Therapists’ notes and transcripts from the
semistructured interviews were used to understand clients’
perception of the intervention. Results: Thematic analyses
of seven exit interviews suggested the primary perceived
outcomes of the intervention included: increased community
involvement; development of planning skills; and the
development of coping skills. These were facilitated by the
therapeutic relationship between the client and therapist.
Conclusions: This project provides preliminary support for the
I-CAN as a participant-centered method for individuals with
SSD to develop skills in the community. Implications for practice
and future research are presented.
Keywords: Community participation, recovery, recreational
therapy, schizophrenia spectrum disorders
Introduction
Schizophrenia spectrum disorders (SSD) are a diagnostic group
associated with severe and persistent mental illness affecting
approximately 1% of the general population [1,2]. People with
Correspondence: Gretchen Snethen, PhD, Department of Rehabilitation Sciences, Temple University, 1700 N. Broad, Philadelphia, PA, 19122 USA.
Tel: 215-204-2748. E-mail: gsnethen@temple.edu
(Accepted December 2011)
1575
Implications for Rehabilitation
• The Independence through Community Access and
Navigation intervention uses community-based rec-
reation to promote community participation through
the development of competence, autonomy and
relatedness.
• The promotion of independent community-based
recreation participation through supported participa-
tion may increase planning abilities, coping skills and
community participation.
• An interactive leadership style, where control is bal-
anced between therapist and client, may help facilitate
perceived competence and autonomy.
SSD experience chronic isolation [3–5], elevated morbidity [6],
imprisonment [7], poverty [7–9] and homelessness [7] rates
when compared to the general population. Defining character-
istics of SSD include positive symptoms such as hallucinations,
intrusive thoughts and delusions; negative symptoms such as
lacking the ability to experience pleasure, lacking the motiva-
tion to initiate behavior and lacking the ability to empathize;
and cognitive dysfunctions including disorganized thought,
inability to plan, and memory deficits [10,11]. Additionally,
individuals with SSD have functional impairments that affect
such things as planning and attending to multiple tasks; pro-
ducing and receiving verbal and nonverbal communication;
forming and maintaining relationships; self-care; and accessing
community services among others [4,12–15].
Mental illnesses such as SSD are still highly stigmatized
within the general population and both the real experiences
of stigma and perceived stigma often prevent community
participation [16,17]. In summarizing the negative effects of
stigma on public health, Link and Phelan [18] suggested that
 1576 G. Snethen et al.
internalized stigma can cause individuals with SSD to “act
less confidently and more defensively with others,” (p. 528)
ultimately leading to avoidance and isolation.
In order to address functional impairments, mental-health
professionals have moved toward a recovery model in which
recovery is viewed as a process and the client is an active par-
ticipant in his or her treatment [19–22]. Interventions follow-
ing this framework often target activities of daily living [17]
and employment [17]; however, involvement in recreation
and leisure activities is a less-studied treatment area that has
the opportunity to address both social and functional impair-
ments, while increasing life satisfaction [17,23,24].
Leisure and mental health treatment
Recreation and leisure activities as treatment areas for SSD
Disabil Rehabil Downloaded from informahealthcare.com by University of Queensland on 09/20/13
are understudied areas that may have positive benefits with
this population [23]. Recently, Iwasaki, Coyle and Shank [24]
have proposed meaningful leisure participation as a facilita-
tor in holistic recovery in individuals with severe mental ill-
ness, citing benefits in (1) health (i.e. physical and mental),
(2) identity formation, (3) coping, (4) social connectedness,
(5) human development and (6) positive emotions. Similarly,
researchers purport the benefits of leisure participation for
individuals with SSD in improving community functioning,
gaining and practicing social skills, increasing physical skills,
accomplishing goals and developing competencies [25,26].
For personal use only.
Furthermore, individuals with SSD who have high motiva-
tion to participate in leisure activities are also further in the
recovery process [26]. Another study determined that leisure
participation had positive impacts on self-efficacy and per-
ceived control [27].
Recreation and leisure activities have inherent social quali-
ties that may provide opportunities for the development of
social networks [28,29]. Sorgaardand et al. [30] found high
social integration and satisfaction with social attachments in
adults with SSD was positively correlated with satisfaction
with leisure activities. Individuals with larger nonkin social
networks are more likely to have better long-term outcomes
than individuals with social networks comprising primarily
family members [31]. This suggests that friendship networks
may provide individuals with resources familial networks do
not. Furthermore, Evret et al. [32] found social integration
to be positively correlated with improved overall function-
ing. Conversely, those who participate in fewer social leisure
activities also experience greater social isolation [4]. This
suggests individuals with more diverse social networks have
higher levels of integration. Social integration of individuals
with SSD is also associated with earlier treatment of symp-
toms. In addition, among adults with SSD, social interaction
is more likely to occur outside the home [33], which provides
support for community-based interventions.
Intervention framework and implementation
In 2009, the Schizophrenia Patient Outcomes Research Team
recommended that in order for interventions to have a lasting
Disability & Rehabilitation
impact, the implementation of interventions targeting func-
tional improvements should occur in the community [34]. The
Independence through Community Access and Navigation
(I-CAN) intervention [35] is theoretically grounded in self-
determination theory (SDT) which posits the meeting of basic
psychological needs of autonomy, competence and related-
ness is fundamental for motivation and well-being [36,37].
Autonomy involves people’s abilities to choose and endorse
the activities in which they are involved [38]. Mancini [20]
reported that autonomy in treatment and participation in
meaningful activities is core to the recovery process.To pro-
mote autonomy, clients were actively involved in decision
making during each stage of the intervention, suggesting an
interactive style between therapist and client, which has been
shown to be effective within this population [27]. Competence
refers to an individual’s mastery within given situations and is
predictive of community participation [2]. The coparticipa-
tion stage allowed for participants to experience the activity
in the actual environment with desired support in order to
develop competence for independent participation. Finally,
relatedness involves an individual’s need to be connected to
others and includes one’s need to be an equal contributor to
relationships. That is, individuals need to receive the benefits
of social interaction, but also believe their contribution to the
relationship is valuable. Individuals with SSD are often isolated
[4,5], and Sorgaard et al. [30] suggest leisure activities provide
individuals with access to others. More specifically, by target-
ing participation in community-based recreational activities
clients were given access to individuals with common interest,
with whom they could form potential relationships. Thus, by
addressing the basic psychological needs of competence, relat-
edness and autonomy, the opportunity to promote sustained
improvements in overall functioning exists [38–40].
The I-CAN intervention is a recreational-therapy (RT)
intervention modeled after the individualized placement and
support (IPS) model [41]. Central tenets derived from the IPS
model were concepts of client preference, rapid placement,
providing supports and skill training in vivo and time-unlim-
ited support [42]. The IPS model was developed in supported
employment interventions [42], but has also been used in
supported education interventions [43]. For this intervention,
the IPS model is used to support community-based recreation
participation, matching clients with interest-based activities
to promote autonomy and providing onsite training through
coparticipation.
The conceptualization of functioning within the I-CAN
intervention is derived from the World Health Organization’s
International Classification of Functioning, Disability, and
Health (ICF) [44]. The ICF provides a model of the interrela-
tionship of functioning and also provides the background for
the targeted areas of rehabilitation and increased participation
[45,46]. The ICF is not population-specific, but rather classi-
fies areas of functioning that are applicable to all individuals.
It is beneficial for rehabilitation professionals to use the ICF
as it provides a common language for practitioners to use to
communicate functional impairments and improvements to
other professionals [47]. For the purposes of this study, the

researchers focused on the activities and participation section
of the ICF, specifically, the functional assessment used for
the I-CAN intervention was developed using activity codes
from the major life areas (d8) and community, social and civic
life (d9) chapters of the activities and participation section.
Furthermore, the activities assessed were specific to the com-
munity in which the intervention took place.
Method
Study design and intervention
The intervention was facilitated by two master’s-level trained
recreational therapists. The lead author, who was involved
with the initial development of the intervention, was one of
the implementing recreational therapists and participated
in training the other recreational therapist. Like the IPS,
Disabil Rehabil Downloaded from informahealthcare.com by University of Queensland on 09/20/13
Outcomes from the I-CAN intervention 1577
participation. Clients who expressed interest in the study and
met inclusion requirements met with the lead author who
completed the consent and enrollment process. The univer-
sity institutional review board and the independent CMHC
institutional review approved all study methods.
Data collection
Data were collected in May–July 2010 in a small city in the
Midwestern United States. The project employed a rolling
enrollment with each participant engaging in the project for
10 weeks. Both qualitative and quantitative data were used
to address the research questions of the pilot intervention.
Individuals participated in a structured interview to confirm
diagnosis [52], an initial semistructured interview, nine modi-
fied day-reconstruction methods (DRMs) [53] interviews and
a final exit interview in combination with the I-CAN inter-

the I-CAN intervention was designed to be time unlimited;
however, due to feasibility constraints, these outcomes of pilot
intervention took place over a 9-week period with the entire
data-collection period occurring over 10 weeks. The recre-
ational therapists met with each client for approximately 30
hours (excluding data-collection times) over the course of the
9-week pilot intervention.
The purpose of this study was to pilot test and evaluate the
perceived value and effectiveness of the I-CAN intervention
in adults with SSD receiving assertive community-treatment
(ACT) services. Information about the development of the
For personal use only.
vention. The initial semistructured interview and the DRM
interviews provided data to understand the daily community
participation that occurred. The DRM interviews occurred
three times each during week 1, 4 and 10 of the study and
required participants to identify types of activity and moti-
vation for participation. Table I presents the topical areas
addressed by the exit interview. The initial and exit semistruc-
tured interviews lasted 30–45 minutes per interview.
Finally, the recreational therapists’ clinical notes were
included as data to provide information about the progress
of each individual client. These progress notes included

intervention and the protocol are described in detail elsewhere
[35,48]. This project focused on the following key questions:
(1) What are the perceived outcomes of the intervention? (2)
Are there facilitating or limiting variables that contribute to
the outcomes?
information from the initial assessment and throughout the
intervention, and identified participants’ initial goals, prog-
ress and continuing goals. Summaries were provided to the
client’s primary case manager upon completion of the pilot
intervention.

Participants
All participants in this study received ACT services from a
local community mental health center (CMHC). ACT is a
best-practice model that serves individuals with severe men-
tal illness who experience significant functional impairment.
ACT services include activities of daily living, vocational
assistance, counseling, medication support, supported hous-
ing, financial assistance, social skills and problem-solving
skills [49]. While one of the goals of ACT is normalized com-
munity functioning, services rarely target essential elements
of community integration (i.e. social interaction and partici-
pation in meaningful activities) and have demonstrated lim-
ited impact on social functioning [50,51]. Participants were
recruited via ACT-team case managers based on inclusion
criteria of (1) diagnosis of SSD, (2) 18 years of age or older and
(3) no communicable conditions that prevented community
Analyses
DRM data were coded by activity location (i.e. home, commu-
nity, CMHC). These data were summed across participants to
capture an idea of the number of activities participants iden-
tified during the week prior to the intervention, the fourth
week of the pilot intervention and the final week of the pilot
intervention. Additionally, data regarding the presence of oth-
ers was summed across locations, in order to gain an under-
standing of where people with SSD are more likely to be in
contact with friends.
Using an open coding system to analyze data, the first
author conducted a thematic analysis of the clients’ perceived
value and outcomes of the intervention and factors influenc-
ing outcomes. All analyses utilized the modified version of
the constant comparison method presented by Boeije [54],

Table I. Exit interview topical outline.

Exit interview
Intervention description
Could you describe your involvement in the
intervention?
What are the things that you did?
Why were those things chosen?
Intervention perception
What are your thoughts about the intervention? About the assessment?
Would you do this again? Why/Why not?
What do you think the purpose of this intervention was? Is this important to you?
Should this type of program be available to others receiving mental-health services? Why/Why not?

© 2012 Informa UK, Ltd.

 1578 G. Snethen et al.
in which initial codes are identified and then compiled into
broader categories and eventually themes. Data were analyzed
within the individual and then across individuals. The initial
interview, conducted during the first week of DRM interviews,
and the initial goals set by participants were analyzed to gain
an understanding of the participants’ day-to-day life prior to
the intervention. The exit interviews were initially coded to
identify preliminary themes to ensure data analysis reflected
participant perceptions, and then compared to the clinician
notes and DRM interviews that directly related to interven-
tion procedures to clarify and further expand developing
themes. The multi-interview format allowed the researchers
to look for perceived changes within the individual and across
the study group. The majority of the data for this article stems
from the exit interviews and the clinical notes in which par-
ticipants had the opportunity to evaluate the intervention.
Disabil Rehabil Downloaded from informahealthcare.com by University of Queensland on 09/20/13
brief description of the participants*. Of the eight participants,
seven had complete data; however, one participant completed
only 6 weeks of the intervention owing to incarceration.
Daily participation
Throughout the data-collection period, participants identi-
fied involvement in few activity episodes during the DRM-
collection periods. The average number of activities based on
all end of day DRM reports were M = 3.8 (standard deviation
(sd) = 0.95), M = 4.7 (sd = 0.57) and M = 4.3 (sd = 1.1) for
DRM collection during weeks 1, 4 and 10, respectively. Table III
presents the location of activity participation for the individuals
in this study. In relation to community-based activities, week
4, which was during the coparticipation phase of the interven-
tion, had the highest number of activities that took place within

Member checks were conducted after the completion of Table III. Numbera of identified activities by participant.
the final interview to ensure description of daily participation Community Home CMHC
and intended goals of the intervention were accurate; partici- Week 1 4b 10 1 4 10 1 4 10
pants did not identify any issues with the presentation of this Arnie 3 4 4 8 10 6 1 0 2
section of the data. Additionally, a peer reviewer checked the Jerome 3 7 6 9 8 8 2 2 4
coding scheme for credibility. Tracy 4 4 4 11 9 7 0 0 0
Sean 2 5 – 5 2 – – – –
Results Art 1 4 2 9 11 11 1 2 1
Kendra 0 3 0 6 7 11 0 1 0
Participants Mary 2 3 3 7 9 6 1 1 1
A total of 10 ACT consumers with SSD enrolled in this proj-
For personal use only.

Benc 2 4 1 10 9 4 0 0 0
ect; however, two dropped out before the intervention began, Total 17 34 20 65 65 53 5 6 8
one citing health reasons and the other refusing requests CMHC, community mental health center.
aNumber does not reflect duration.
for additional contacts. The remaining five males and three bCoparticipation occurred here.

females ranged from 24–57 years of age. Table II presents a cBen only completed 2 days of week 10 DRM.

Table II. Participant description.

Participanta Sex Ethnicity Age Characteristics
Jerome M African American 30 Jerome had a high frequency experience of intrusive thoughts and delusions of grandeur that often
made community participation difficult. He was eager to learn new things and had a high desire to
meet new people. Jerome had no observable negative symptoms. He admitted to being stigmatized
within the community. Jerome had a history of substance abuse.
Kendra F White 43 Kendra was not currently experiencing positive symptoms; however, she exhibited severe
impairments in initiating behavior and planning, and spent most days in bed or watching television.
She also centered her life around men and often felt used for sex. Kendra had a history of alcohol
abuse.
Mary F White 46 Mary experienced positive symptoms of paranoia. She exhibited communication impairments
such as: difficulty processing information and low verbal-communication skills. She self-identified
having depression and a learning disability. Mary exhibited negative symptoms of flattened affect,
anhedonia and amotivation. She also experienced stigma within the community. Mary had a history
of substance abuse.
Arnie M White 54 Arnie frequently experienced intrusive thoughts that negatively affected his confidence in
performing activities. He exhibited flattened affect, amotivation, difficulty processing information
and experienced severe anxiety regarding new situations.
Tracy F White 27 Tracy frequently experienced positive symptoms (hearing voices) and exhibited flattened affect,
impairments in initiating behavior and planning and anxiety about scheduling activities.
Sean M White 25 Sean frequently experienced positive symptoms (hearing voices) and disorganized thought. He
often had difficulty processing information and verbalizing his thoughts. Sean also had an active
substance-abuse disorder.
Art M White 51 Art experienced delusions he presented as reality. Art had severe negative symptoms and cognitive
dysfunction, resulting in severe impairments in communication, including written and verbal. Art
also had severe impairments in planning and initiating behavior, spending most of his days in bed.
Ben M White 43 Ben experienced positive symptoms of paranoia, hearing voices and delusions. He had difficulty
processing information and verbalizing thought. Ben also had severe impairments in planning and
initiating behavior, and spent most of his time in his apartment. Ben also had an active substance-
abuse disorder.
aPseudonyms
are used in place of the participants’ real names.

Disability & Rehabilitation

 Outcomes from the I-CAN intervention 1579

Table IV. Numbera activity instances by location and presence of others.

Alone Friends Providers
Week 1 4 10 Total 1 4 10 Total 1 4 10 Total
Home 43 47 33 123 6 – – 6 5 6 4 15
Community 5 4 5 14 5 15 7 27 1 8 3 12
CMHC – – – – 2 1 4 7 3 2 5 10
Total 48 52 38 137 13 16 11 40 9 16 12 37
CMHC, community mental-health center.
a
Does not indicate the number of individuals present.

the community. It is important to note, these activities neither Table V. Code count by participant.
reflect the duration of different activities nor the specific type of Perceived outcomes Perceived facilitator
activity, only the number and location of activities. Community Therapist/client
During half of the activities listed in the DRM, partici- Participant involvement Planning Coping interaction
pants identified being alone. Community-based activities had Arnie 5 3 4 9
a higher occurrence of participation with friends than any Jerome 8 1 6 1
Disabil Rehabil Downloaded from informahealthcare.com by University of Queensland on 09/20/13

other location and home-based activities had a higher occur- Tracy 4 2 4 3

rence of solitary participation. Like community participation, Art 6 0 3 4
activity involvement with friends occurred most frequently Kendra 4 5 1 1
during week 4. Table IV presents a summary of the presence Mary 7 1 2 2
of others by location. Ben 2 2 1 4
Total 36 14 21 24
Perceived outcomes
Participants who completed the exit interview identified three
having activities to do and expanded upon this with the fol-
primary outcomes from the intervention: (1) community
lowing statement:
involvement, (2) planning and (3) coping. These themes were
initially coded from the exit interviews. Table V represents the
For personal use only.

number of times each theme was coded within each partici-
pant during the exit interview. This table is representative of
both the perceived-outcomes themes and perceived facilita-
tors discussed later. It is important to note, these themes were
also further developed through the information from the
clinical notes and the DRM interviews.
All seven individuals who participated in the exit interview
identified positive outcomes from their participation. In an
overarching statement, Jerome identified the following:
I think [the intervention] was very meaningful. Because you’ve
shown me that there’s things out there I can do that, if I just try
certain things, I never know, I’ll probably enjoy them. You showed
me there’s things to do in the community other than just things I’ve
been doing…Just find that having somebody to talk to, you know?
For some things, I got off my chest, you know, that was on my chest
for a long time and there was nothing I felt like I was able to do
about it, you know? I got it off my chest and it made me feel better,
you know? I had fun these past weeks, you know?+
Perceived outcomes are presented in the following catego-
ries: community involvement, planning and coping skills.
Community involvement
Based on the participant exit interviews and the therapists’
notes, all participants increased their level of community par-
ticipation. At the start of the intervention, Jerome and Tracy
were the most integrated into their community, accessing it
both for goods and services as well as for interest-based activi-
ties. However, even these individuals believed they increased
community-participation levels. When asked what if he per-
ceived benefits from the intervention, Jerome initially stated
Activities means that you’re not locked up, you know? When
the door is out there and you can’t get out, you can’t do nothing.
That’s a reminder that I can get out and do stuff, not locked behind
the door.
Prior to the intervention, Jerome’s definition of com-
munity was freedom from an inpatient facility and jail; his
description of activities suggests an increased perception in
freedom and greater connection to the community. Tracy,
who was the only participant with her own form of trans-
portation, began to access her community more regularly
for activities other than shopping. By the end of the inter-
vention, Tracy was going to the pool at least once per week,
had made plans to go to a free knitting class at the library
with her sister and was leading her neighbors in simple yoga
techniques learned in a local yoga class in the courtyard of
their apartment.
The only initial goal Arnie was able to identify was riding
the bus, which, by the end of the intervention, he was able
to do independently. During his exit interview, Arnie also
identified interest in learning to participate in other commu-
nity-based activities (i.e. learning to use the computer at the
apartment commons and walking).
Finally, even Ben and Kendra, who despite their limited
contact with the recreational therapist because of sleeping
through or otherwise missing appointments, believed they
increased their participation in the community. Kendra,
who could only identify sleeping as the activity she partici-
pated in prior to the intervention, identified she went to the
library and “out to get tea” as a direct result of the interven-
tion. More importantly, she identified both an increased
desire to participate in the community and the importance

© 2012 Informa UK, Ltd.

 1580 G. Snethen et al.
of community participation. Stating, “just talking about
my behavior and what I do and what I don’t do. Making
me realize the things I need to do more of. Regardless of
whether I sleep one night or not, I need to get out and do
things.” This desire to get out and do things was echoed by
Ben in that he believed it was an avenue to meet others,
“Oh, it’s [socializing] so important. It’ll get my mind back in
order, and I’ll find things to do, different friends, and even-
tually get back into some kind of work hopefully, or study. I
don’t want to just be lazy.”
Planning
From the assessment that occurred at the beginning of the
intervention all participants exhibited functional deficits in
the ability to plan and organize their days. Ben and Sean
both identified a lack of daily structure and an inability to
Disabil Rehabil Downloaded from informahealthcare.com by University of Queensland on 09/20/13
independently structure daily routines. Ben stated, “I’ve
been taking it as it comes, but I’ve been wanting to get a
set routine,” while Sean stated, “[I’d like] more structured
activities.”
By the end of the intervention, Jerome and Tracy were able
to set weekly participation goals. Jerome identified exercising
5 days/week as one of his weekly goals. While Tracy still had
difficulty following through with daily plans, she made prog-
ress in setting weekly goals.
I just do the best I can do but I still don’t know. I was hesitant
For personal use only.
about making plans because I don’t know [how] I’m going to feel.
And then like with the yoga and doing it on my own, I could[n’t]
do it on the days that I was laying in bed on the same day I said I
was going to do it. But I was able to do it on a day that I felt half
way decent.
At the intervention completion, Ben still identified the
need to develop his abilities to make and follow through
with plans. Ben felt the most structure he experienced was
in relation to the intervention. While Arnie’s days were
structured around activities of daily living, he could not use
the bus independently prior to the start of the intervention.
When asked about understanding the bus schedule, Arnie
stated, “At the very beginning, there was anxiety big time…
It’s over with now.” Through participation in the interven-
tion, Arnie was able to overcome his anxiety about the bus
schedule and learn to use the appropriate bus for different
appointments, “just by you writing down things and stuff…
I need to write down things myself, too. It all works hand
in hand.”
Coping
During the initial interview and the intervention assess-
ment, participants identified stress and anxiety as a barrier
to participation, and through participation in the interven-
tion, reported developing coping skills to manage stress
and anxiety. Jerome, who often had intrusive thoughts that
made him feel depressed,was able to identify an activity to
decrease stress and feel better about himself, “I learned I can
go walk when I’m stressed out. Hop on the bus and go out
to the trail and go down the trail.” Similarly, at the end of
Disability & Rehabilitation
the intervention, Mary was able to list activities she could do
both at home and in the community when she was feeling
stressed or overwhelmed. This was important for her, as she
had visited the emergency room twice in a 2-week period for
psychiatric services, without consideration of other options.
By the end of the intervention, she had identified the impor-
tance of finding activities she could do that helped her feel
better when feeling depressed.
When discussing the activities she and the recreational
therapist chose to participate in, Tracy identified the per-
ceived participation benefits, “And they’re helpful. Like yoga is
good for your body. And the pool is good to be in the sun for
Vitamin D, or whatever…” Similarly, when asked why com-
munity participation was important to her, Kendra stated, “It’s
just healthy for you physically and mentally.”
Mediating factors
Based on the participant exit interviews, it was found that
two factors related to the intervention or the study design
had an impact on the intervention outcomes. The first,
therapist/client interaction was a facilitator of outcomes;
the second, the limiting factors related to the pilot study
design.
Therapist/client interaction
A contributing factor to the intervention outcomes was the
therapeutic relationship that developed and the coparticipa-
tion that occurred between the recreational therapist and the
clients. All participants identified this theme (see Table V).
This relationship appears to be qualitatively different from
the relationships clients described with their other mental-
health professionals. Jerome referred to the recreational
therapist as his “therapist sister” identifying that she helped
him with his day-to-day well-being. During the assess-
ment, Art identified that he did not enjoy talking to people
because of his speech impairment. When asked if he still felt
that way, Art clarified that he still does not feel comfortable
talking with others, but that he felt comfortable talking to
the recreational therapists involved in the study. Ben felt his
recreational therapist motivated him more so than his other
mental-health professional.
Somehow [the recreational therapist] perk[s] me up and make[s]
me want to do more things for myself... I think [she was] concerned
about my mental health, and my physical health, and my future.
How so? I can tell by the way [she] treat[s] me. I think [the recre-
ational therapist] has shown me more concern than most types all
the years I’ve been here.
In talking about the therapist/client interaction, five of the
participants discussed the frequency with which the recre-
ational therapist encouraged autonomous behavior. The client
identified the activities focused on within the intervention
during the initial assessment; however, these five participants
independently discussed having the therapist encourage them
to make autonomous decisions.
The presence of the recreational therapist during the copar-
ticipation portion of the intervention was also valued and

contributed to the intervention outcomes. Arnie summarized
his experience with learning the bus route in the following
vignette:
Then, as days go on and weeks go on, we get on the bus and stuff,
that means that I was more comfortable with you there with me,
knowing that where to go and where not to. You’ve been a big help
to me on the bus route. Now that you’re leaving, I stood there on
my own on my bus route on my own, what you wrote down, what I
wrote down, too…
The involvement of the recreational therapist was also
beneficial during new tasks that required interaction with
community members. Sean experienced social anxiety when
interacting with community-service providers, and admitted
to running away after asking for a job application. However,
during the coparticipation, Sean was able to ask the art
Disabil Rehabil Downloaded from informahealthcare.com by University of Queensland on 09/20/13
museum curator questions as well as ask for a scholarship
application from a local community gym.
Coparticipation was also seen as beneficial for developing
confidence in the actual setting. The following excerpt from
Tracy’s exit interview not only identified the importance of
coparticipation for herself, but she also generalized it to the
broader purpose of the intervention.
When you’re by yourself. I know that I was. When I was by–– I
was by myself a lot for awhile. Going to places, whether it be the
hospital or to the store, whatever. And I was scared at first. You
For personal use only.
know you just have all this. You’re just scared. You know some-
thing. You’re suffering on the inside. And you got to try to make
everybody else think you’re okay… But I think it helps having
somebody there so that if you like kind of go there. Just like if you
got a kid and you took them somewhere, and then they were able
to learn because they got adults or whatever to go on their own.…
And then they were able to learn that that’s the same with mental
illness. If you go a couple of times with someone, and, then you’ll
feel better doing it on your own.
This also speaks to the importance of developing skills in
the community as opposed to strictly in a controlled envi-
ronment. Identifying the skill in one setting did not always
transfer to successful participation. Amotivation often
made it difficult for individuals to complete tasks on their
own. For example, Ben, who had the Young Men’s Christian
Association application prior to the intervention, admit-
ted he would not have turned the application in without
the support of his therapist. The presence of the therapist
gave what Arnie termed “moral support” so the participant
could develop the skills to eventually complete the activities
independently.
Finally, individuals in transition, particularly transition
that was unresolved (i.e. eviction, incarceration) had difficulty
focusing on the goals they developed with their recreational
therapist. During intervention sessions, Ben was fixated on
looking for an apartment, and needed an intermittent goals-
clarification session to explain the role of the recreational
therapist. Even though Sean left jail prior to the end of his
intervention timeline, he was receiving threats from someone
in the community, and was therefore, frequently not available
for participation.
© 2012 Informa UK, Ltd.
Outcomes from the I-CAN intervention 1581
Discussion and implications
The results of this study provide provisional support for the
use of the I-CAN intervention in a community mental-health
setting with adults with SSD, particularly with regard to com-
munity involvement, planning and coping skills. Additionally,
the importance of the interaction between the recreational
therapist and participant is discussed in relation to facilitat-
ing outcomes. While the results of this pilot study are limited
to the individuals who participated, the consistent outcomes
with participants are promising. Additionally, the identified
satisfaction and desire to continue participation is impor-
tant when considering Mancini’s [20] recommendations for
autonomy in treatment and involvement in meaningful activi-
ties as essential to implementing interventions consistent with
the mental-health recovery model. While one of the overarch-
ing aims of this intervention was to increase social interaction
in adults with SSD, the time frame of the intervention did not
allow for maintained social interaction. However, social inter-
action during the coparticipation section and community
participation increased during the intervention. Yilmaz et al.
[33] found that individuals with SSD who had access to recre-
ational activities within the community also identified having
larger friend networks, suggesting that participation in the
intervention has the potential to increase social interaction.
It is important to note, the average number of activity
episodes identified during the present DRM was consider-
ably less than those in typical DRM studies, which suggest an
average of 15 activity episodes per day [53]. This speaks to
the limited variety in activity involvement of the participants
in this study. It is also important to note, the greatest amount
of community participation occurred during the middle of
the intervention, specifically when the recreational therapist
coparticipated with the client. Similarly, this is when partici-
pants identified more frequent interaction with others.
In relation to the SDT constructs, the I-CAN was suc-
cessful in increasing autonomy and competence. While
autonomy may appear to be an easier outcome, it was not
something that participants independently integrated into
the intervention. The RT worked with the client to ini-
tially identify interest-based activities; beyond that, the
RT encouraged independent decisions and reinforced par-
ticipation based on self-interest, rather than participation
to please the therapist. Given the functional impairments
and cognitive deficits within this population [12,14,55,56],
developing competence took repetition of the activity.
The coparticipation phase provided the opportunity for
the therapist to provide immediate feedback and encour-
age participation. Participants who achieved some level
of independent participation received reinforcement from
the therapist through continued communication and were
able to problem-solve concerns for future participation. As
discussed earlier, the length of the I-CAN pilot interven-
tion was not long enough to increase sustained relatedness
in participants. Because literature [30] suggests increased
community participation, and participation in common-in-
terest–based activities will increase relatedness and partici-
pants in this pilot study increased community participation,
 1582 G. Snethen et al.
the researchers suggest that continued participation in the
intervention would likely increase relatedness as well.
Implications for practice
The results of this pilot-intervention study point to the
possibilities the I-CAN intervention can play in SSD recov-
ery. Integrating interest-based activities and the theoreti-
cal components of SDT (i.e. competence, relatedness and
autonomy) into mental-health interventions can help indi-
viduals with SSD function more successfully within their
communities.
An interactive leadership style promotes increased lev-
els of perceived control [27], which is consistent with the
findings in this study. The interaction between therapist
and client occurred at all stages of the intervention (i.e. goal
development, activity participation, goal evaluation), and
Disabil Rehabil Downloaded from informahealthcare.com by University of Queensland on 09/20/13
was cited as a meaningful component of the intervention
by all participants. This further provides support for the
integration of mental-health professionals into the facili-
tation of community-based recreation activities with this
population. In order to increase competence, it is important
that the client perceives the coparticipation phase as close
to independent participation as possible, which Austin [57]
also provides support for by describing recreational thera-
pists as a therapist friend. Similarly, psychiatric literature
had suggested clients with a good alliance with their thera-
pists are more likely to adhere to treatment recommenda-
For personal use only.
tions [58]. Motivational interviewing has been shown to be
effective with people with SSD and substance-abuse issues
[59] and it appears that the elements of the approach can
also be effectively applied in enabling community par-
ticipation. This was evidenced by the use of motivational
interviewing during the assessment portion of the I-CAN,
which helped the recreational therapist understand indi-
viduals’ motivations for participation and facilitated more
natural interactions during coparticipation. Furthermore,
the coparticipation was an integral part of the intervention,
and should be utilized as long as it takes for the individual
to develop both the actual and perceived competence to
participate independently. During coparticipation, it was
imperative that the therapist provided consistent, positive
reinforcement. For future implementation, this can help
the participant accurately evaluate his or her behavior and,
eventually, recognize mastery experiences.
Given the high rates of unemployment that exist in
this population [7,8], providing interventions that address
the development of skills needed to access community in
nonwork-oriented settings is particularly relevant to recov-
ery. At the end of the pilot intervention, participants in
this study would not be considered to be active community
participants; however, they demonstrated increased par-
ticipation indicating this intervention can start to increase
community participation and would likely, with time,
increase community participation even more. Focusing on
interest-based activities and developing the skills and com-
petence for individuals to participate independently has
the potential to create lasting change and increase social
Disability & Rehabilitation
relationships with individuals who have similar interests.
Furthermore, participants identified a desire to increase
community participation, which is particularly relevant,
given the pervasiveness of amotivation and its impact on
functioning [60,61].
The outcome related to planning was particularly interest-
ing. The inability to plan and initiate behavior are functional
impairments often related to negative symptoms and cogni-
tive impairments [55,62]. Addressing such deficits through an
individualized intervention of this type has the possibility of
developing skills that have clear impact across functional areas
and can complement other interventions. While not specifi-
cally targeted, the identification of coping skills is important
for this population, as stress and anxiety can trigger psychotic
episodes [63,64].
Implementing this intervention as time unlimited would
likely address some of the limiting factors that were identi-
fied. The IPS model identifies unlimited support as one of the
elemental factors [42]. While this was not feasible for this pilot
intervention, the results presented here provide initial sup-
port for the implementation the I-CAN as a time-unlimited
intervention. Furthermore, implementation should focus on
participation in the community, as opposed to skills training
in a clinical environment [65]. Providing ongoing support in
community participation will likely vary in intensity as indi-
viduals become more confident in their abilities to participate
independently.
Implications for research
This pilot intervention was an initial step in understanding the
perceived outcomes of the I-CAN intervention. Understanding
the outcomes of the I-CAN intervention from the partici-
pants’ perspectives provides initial groundwork for identify-
ing more objective outcome measures to use in future studies.
While the findings suggest lengthening the intervention will
make increased social interactions a more realized outcome,
researchers should address how participation in community-
based activities is related to social interaction and whether or
not individuals with SSD increase social interaction through
increased community participation. Intervention research
with a larger sample and experimental controls is necessary
to determine the effectiveness of the I-CAN intervention on
community functioning in adults with SSD.
Limitations
This study was exploratory in nature, and therefore the out-
comes of the intervention should be viewed as limited to
(1) the perception of the participants in this study and (2)
potential areas for future research to address. Given the small
sample size, statistical analyses were limited to descriptive
statistics and should be viewed as complementary infor-
mation to the participants’ perception of the intervention.
Related to diagnosis, it was confirmed that participants in
this study had a SSD; however, no information about the
specific diagnosis, levels of symptoms or medication history
and adherence were available. Participants were recipients

of the same level of services, which indicates a similar level
of functioning, but future research should consider the
identification of specific diagnoses as well as objective mea-
sures of symptomology.
Summary
Community mental-health professionals continue to focus on
recovery, rather than only symptom reduction [19–22]. While
RT services are often found in inpatient psychiatric facilities,
they are less available in CMHCs; however, these services
would complement the current services delivered by CMHC.
This study provides initial support for the I-CAN interven-
tion in increasing community participation. Mental-health
professionals should consider interest-based interventions
that target community participation by occurring primarily
Disabil Rehabil Downloaded from informahealthcare.com by University of Queensland on 09/20/13
within the community. Individuals with SSD can benefit by
incorporating interests into treatment in order to develop
personally meaningful interventions that provide the oppor-
tunity to create more lasting change and facilitate the process
of recovery.
Acknowledgments
The authors would like to thank Rachel Smith for her assis-
tance with the facilitation of the Independence through
For personal use only.
Community Access and Navigation intervention.
Declaration of Interest: The authors report no conflict of
interest.
References
1. Ruggeri M, Leese M, Thornicroft G, Bisoffi G, Tansella M. Definition
and prevalence of severe and persistent mental illness. Br J Psychiatry
2000;177:149–155.
2. Bowie CR, Leung WW, Reichenberg A, McClure MM, Patterson TL,
Heaton RK, Harvey PD. Predicting schizophrenia patients’ real-world
behavior with specific neuropsychological and functional capacity
measures. Biol Psychiatry 2008;63:505–511.
3. Drake RJ, Haley CJ, Akhtar S, Lewis SW. Causes and consequences
of duration of untreated psychosis in schizophrenia. Br J Psychiatry
2000;177:511–515.
4. Graham C, Arthur A, Howard R. The social functioning of older
adults with schizophrenia. Aging Ment Health 2002;6:149–152.
5. Nilsson LL, Lögdberg B. Dead and forgotten–postmortem time before
discovery as indicator of social isolation and inadequate mental
healthcare in schizophrenia. Schizophr Res 2008;102:337–339.
6. Everett A, Mahler J, Biblin J, Ganguli R, Mauer B. Improving the
health of mental health consumers: effective policies and practices.
Int J Ment Health 2008;37:8–48.
7. Perese EF. Stigma, poverty, and vicitmization: roadblocks to recov-
ery for individuals with severe mental illness. J Am Psych Nurses
2007;13:285–295.
8. El-Mallakh P. Poverty and self-care in individuals with diabetes mel-
litus. Arch Psychiatr Nurs 2007;21:236–237.
9. Morris A, Bloom JR, Kang S. Organizational and individual factors
affecting consumer outcomes of care in mental health services. Adm
Policy Ment Health 2007;34:243–253.
10. American Psychiatric Association. Diagnositic and statistical manual
of mental disorders. 4th ed. text rev. Washington, DC: Author; 2000.
11. Mueser KT, McGurk SR. Schizophrenia. Lancet 2004;363:2063–2072.
12. Cohen AS, Forbes CB, Mann MC, Blanchard JJ. Specific cognitive
deficits and differential domains of social functioning impairment in
schizophrenia. Schizophr Res 2006;81:227–238.
© 2012 Informa UK, Ltd.
Outcomes from the I-CAN intervention 1583
13. Harvey PD, Helldin L, Bowie CR, Heaton RK, Olsson AK, Hjärthag F,
Norlander T, Patterson TL. Performance-based measurement of func-
tional disability in schizophrenia: a cross-national study in the United
States and Sweden. Am J Psychiatry 2009;166:821–827.
14. Medalia A, Thysen J. Insight into neurocognitive dysfunction in
schizophrenia. Schizophr Bull 2008;34:1221–1230.
15. Tenorio-Martínez R, del Carmen Lara-Muñoz M, Medina-Mora ME.
Measurement of problems in activities and participation in patients
with anxiety, depression and schizophrenia using the ICF checklist.
Soc Psychiatry Psychiatr Epidemiol 2009;44:377–384.
16. González-Torres MA, Oraa R, Arístegui M, Fernández-Rivas A,
Guimon J. Stigma and discrimination towards people with schizo-
phrenia and their family members. A qualitative study with focus
groups. Soc Psychiatry Psychiatr Epidemiol 2007;42:14–23.
17. Corrigan PW. Towards an integrated, structural model of psychiatric
rehabilitation. Psychiatr Rehabil J 2003;26:346–358.
18. Link BG, Phelan JC. Stigma and its public health implications. Lancet
2006;367:528–529.
19. Andresen R, Oades L, Caputi P. The experience of recovery from
schizophrenia: towards an empirically validated stage model. Aust N
Z J Psychiatry 2003;37:586–594.
20. Mancini MA. The role of self-efficacy in recovery from serious psychi-
atric disabilities: a qualitative study with fifteen psychiatric survivors.
Qual Soc Work 2007;6:49–74.
21. Mancini MA, Hardiman ER, Lawson HA. Making sense of it all: con-
sumer providers’ theories about factors facilitating and impeding recov-
ery from psychiatric disabilities. Psychiatr Rehabil J 2005;29:48–55.
22. Oades L, Deane F, Crowe T, Lambert WG, Kavanagh D, Lloyd C.
Collaborative recovery: an integrative model for working with individ-
uals who experience chronic and recurring mental illness. Australas
Psychiatry 2005;13:279–284.
23. Rudnick A. Psychiatric leisure rehabilitation: conceptualization and
illustration. Psychiatr Rehabil J 2005;29:63–65.
24. Iwasaki Y, Coyle CP, Shank JW. Leisure as a context for active living,
recovery, health and life quality for persons with mental illness in a
global context. Health Promot Int 2010;25:483–494.
25. Lloyd C, King R, Lampe J, McDougall S. The leisure satisfaction of peo-
ple with psychiatric disabilities. Psychiatr Rehabil J 2001;25:107–113.
26. Lloyd C, King R, McCarthy M. The association between leisure moti-
vation and recovery: a pilot study. Aust Occu Ther J 2007;54:33–41.
27. Pegg S, Patterson I. The impact of a therapeutic recreation program
on community-based consumers of a regional mental health service. J
Park Rec Admin 2002;20:65–89.
28. Coleman D, Iso-Ahola SE. Leisure and health: the role of social sup-
port and self-determination. J Leisure Res 1993;25:111–128.
29. Yanos PT, Moos RH. Determinants of functioning and well-being
among individuals with schizophrenia: an integrated model. Clin
Psychol Rev 2007;27:58–77.
30. Sörgaard KW, Hansson L, Heikkilä J, Vinding HR, Bjarnason O,
Bengtsson-Tops A, Merinder L, et al. Predictors of social relations in
persons with schizophrenia living in the community: a Nordic multi-
centre study. Soc Psychiatry Psychiatr Epidemiol 2001;36:13–19.
31. Erickson DH, Beiser M, Iacono WG. Social support predicts
5-year outcome in first-episode schizophrenia. J Abnorm Psychol
1998;107:681–685.
32. Evert H, Harvey C, Trauer T, Herrman H. The relationship between
social networks and occupational and self-care functioning in people
with psychosis. Soc Psychiatry Psychiatr Epidemiol 2003;38:180–188.
33. Yilmaz M, Josephsson S, Danermark B, Ivarsson AB. Participation by
doing: social interaction in everyday activities among persons with
schizophrenia. Scand J Occup Ther 2008;15:162–172.
34. Kreyenbuhl J, Buchanan RW, Dickerson FB, Dixon LB. Schizophrenia
Patient Outcomes Research Team (PORT). The Schizophrenia Patient
Outcomes Research Team (PORT): updated treatment recommenda-
tions 2009. Schizophr Bull 2010;36:94–103.
35. Snethen G, McCormick BP, Van Puymbroeck M. Independence
through Community Access and Navigation (I-CAN) in adults with
schizophrenia spectrum disorders: theoretical and practical founda-
tions (Part I). Am J Rec Ther 2011;10:25–34.
36. Deci EL, Ryan RM. Intrinsic motivation and self-determination in
human behavior. 1st ed. New York: Plenum Press; 1985.
37. Ryan RM, Deci EL. Self-determination theory and the facilitation of
intrinsic motivation, social development, and well-being. Am Psychol
2000;55:68–78.
38. Deci EL, Vansteenkiste M. Self-determination theory and basic need
satisfaction: understanding human development in positive psychol-
ogy. Recerche di Psichologia 2004;27:17–34.
 1584 G. Snethen et al.
39. Deci EL, Ryan RM. Facilitating optimal motivation and psychological
well-being across life’s domains. Can Psychol 2008;49:14–23.
40. Deci EL, Ryan RM. The “what” and “why” of goal pursuits: human
needs and the self-determination of behavior. Psychol Inquiry
2000;11:227–268.
41. Becker DR, Drake RE. A working life for people with severe mental
illness. 1st ed. New York: Oxford University Press; 2003.
42. Bond GR. Principles of the individual placement and support model:
empirical support. J Psychol Rehabil 1998;22:11–24.
43. Soydan AS. Supported education: a portrait of a psychiatric rehabilita-
tion intervention. Am J of Psychol Rehabil 2004;7:227–248.
44. WHO. International classification of functioning, disability and
health. Geneva, Switzerland: World Health Organization; 2001.
45. Rimmer JH. Use of the ICF in identifying factors that impact partici-
pation in physical activity/rehabilitation among people with disabili-
ties. Disabil Rehabil 2006;28:1087–1095.
46. Stucki G, Cieza A, Ewert T, Kostanjsek N, Chatterji S, Ustün TB.
Application of the International Classification of Functioning,
Disability and Health (ICF) in clinical practice. Disabil Rehabil
2002;24:281–282.
47. Van Puymbroeck M, Porter HR, McCormick BP, Singleton J. The
Disabil Rehabil Downloaded from informahealthcare.com by University of Queensland on 09/20/13
role of the International Classification of Functioning, Disability, and
Health (ICF) in therapeutic recreation practice, research, and educa-
tion in professional issues in therapeutic recreation: on competence
and outcomes. Stumbo NJ, editor. Urbana, IL: Sagamore Publising;
2009. pp 43–57.
48. Snethen G, McCormick BP, Smith RL, Van Puymbroeck M.
Independence through Community Access and Navigation (I-CAN)
in adults with schizophrenia spectrum disorders: treatment planning
and implementation (Part II). Am J Rec Ther 2011;10:35–46.
49. Phillips SD, Burns BJ, Edgar ER, Mueser KT, Linkins KW, Rosenheck
RA, Drake RE, McDonel Herr EC. Moving assertive community treat-
ment into standard practice. Psychiatr Serv 2001;52:771–779.
50. Anders SL. Improving community-based care for the treatment
of schizophrenia: lessons from native Africa. Psychiatr Rehabil J
For personal use only.
2003;27:51–58.
51. Bond GR, Drake RE, Mueser KT, Latimer E. Assertive community
treatment for people with severe mental illness - critical ingredients and
impact on patients. Dis Manag Health Outcomes 2001;9:141–159.
Disability & Rehabilitation
52. Sheehan DV, Lecrubier Y, Sheehan KH, Amorim P, Janavs J,
Weiller E, Hergueta T. Baker R, Dunbar, G. The Mini-International
Neuropsychiatric Interview (MINI): the development and valida-
tion of a structured diagnostic psychiatric interview for DSM-IV and
ICD-10 . J Clin Psych 1998; 59(suppl 20):22–33.
53. Kahneman D, Krueger AB, Schkade DA, Schwarz N, Stone AA. A
survey method for characterizing daily life experience: the day recon-
struction method. Science 2004;306:1776–1780.
54. Boeije H. A purposeful approach to the constant comparative method in
the analysis of qualitative interviews. Qual Quant 2002;36:391–409.
55. Green MF. What are the functional consequences of neurocognitive
deficits in schizophrenia? Am J Psychiatry 1996;153:321–330.
56. Wykes T, Castle DJ. Cognitive dysfunction in schizophrenia. In:
Castle DJ et al., editors. Pharmacological and psychosocial treatments
in schizophrenia. London, UK: Informa UK Ltd; 2009. pp 47–60.
57. Austin DR. Therapeutic recreation: processes and techniques. 6th ed.
Urbana, IL: Sagamore; 2009.
58. Frank AF, Gunderson JG. The role of the therapeutic alliance in the
treatment of schizophrenia. Relationship to course and outcome. Arch
Gen Psychiatry 1990;47:228–236.
59. Miller WR, Rollnick S. Motivational interviewing: preparing people
for change. 2nd ed.New York: Guilford Press; 2002.
60. Addington J, Addington D. Positive and negative symptoms of schizo-
phrenia. Their course and relationship over time. Schizophr Res
1991;5:51–59.
61. Lysaker PH, Davis LW. Social function in schizophrenia and schizo-
affective disorder: associations with personality, symptoms and neu-
rocognition. Health Qual Life Outcomes 2004;2:15.
62. Kirkpatrick B, Fenton WS, Carpenter WT Jr, Marder SR. The NIMH-
MATRICS consensus statement on negative symptoms. Schizophr
Bull 2006;32:214–219.
63. Todman M. Boredom and psychotic disorders: cognitive and motiva-
tional issues. Psychiatry 2003;66:146–167.
64. Bracke P, Bruynooghe K, Verhaeghe M. Boredom during day activity
programs in rehabilitation centers. Sociol Persp 2006;49:191–215.
65. Lehman AF, Kreyenbuhl J, Buchanan RW, Dickerson FB, Dixon
LB, Goldberg R, Green-Paden LD, et al. The Schizophrenia Patient
Outcomes Research Team (PORT): updated treatment recommenda-
tions 2003. Schizophr Bull 2004;30:193–217.