Refined programme theory and underpinning context-mechanism-outcome (CMOC) configurations
| Refined programme theory ‘When service users (SU) are first diagnosed with serious mental illness (SMI), a diagnosis which is frightening to them, they seek out information about their illness. SUs omedications want practitioner support and practitioner advice they can understand and apply to their current and ongoing needs. SUs may seek out individuals with lived experience to validate the experiences they are having, and to learn how others effectively manage living with SMI. As SUs gather information from diverse sources (practitioners, social supports, internet), they are constantly weighing up the pros and cons of medication decisions. It is important to SUs to forge positive working relationships with practitioners who will listen to them, respectfully consider their needs and support their medication decisions whenever possible. SUs are regularly facing lifestyle challenges, some with high stakes, such as pregnancy or serious health side effects. If and when SUs have established therapeutic relationships with practitioners who have their best interests at heart and are competent in their field of expertise, SUs are more apt to seek them out for shared information exchange and decision-making. Regardless of the strength of the SU-practitioner relationship, in high stakes situations, trust is fragile; trust is based on ongoing evidence of practitioners’ motivations to support them. Similarly, SUs need ongoing and non-judgemental support from family members and their social network, including peer support workers’. | |
| CMOC | Evidence sources |
| CMOC 1: first contact When an SU with SMI is first diagnosed, is medicated and has coercive, dehumanising* experiences with practitioners (C), this often derails the development of trusting therapeutic alliances (O) because of feelings of powerlessness (M) and stigmatisation (M). | 38 44 45 68 74 77 79 81 88 95 |
| CMOC 2: relief When an SU with SMI is first diagnosed and is medicated, validation and normalisation of their condition by a respectful, supportive practitioner (C) results in increased relief, hope and optimism (O) due to decreased stigmatisation of living with SMI (M) and increased reassurance (M) that they have a treatable condition. | 43 62 68 71 74 88 |
| CMOC 3: dismissal When an SU with SMI on medications realises practitioners are withholding medication information, and/or excluding, ignoring or dismissing them from medication decisions (C), they are apt to withdraw from the practitioner relationship and make their own medication decisions (O), due to mistrust (M) in the practitioners’ interest in them and their need for more control (M) over decisions affecting their lives. | 40 43 45 59 62 67 68 71 76 77 79–81 83–88 90 |
| CMOC 4: being heard From the start of their relationship onwards, when an SU with SMI on medications is actively engaged by a respectful, supportive practitioner who takes an interest in them and their issues and concerns about their illness, medication and side effects (C), they are more apt to forge a therapeutic alliance with their practitioner (O), because they feel heard and listened to (M) and they trust (M) in the practitioner’s motivations to help them better manage their medications and illness. | 39 43 46 47 53 57 60–62 68 70 78 81–83 88 89 |
| CMOC 5: practitioner information exchange From the start of the therapeutic relationship onwards, when an SU with SMI feels comfortable accessing their practitioner for honest, easy-to-understand and personalised information about their medications (C), they are apt to use the information to prepare for and to cope better with medications and side effects (O), due to development of mutual trust (M) and respect (M) in each other and in the information being exchanged. | 43–45 50 52 56 62 67 70 75–80 83 86 90 94 |
| CMOC 6: seeking more information Whenever an SU with SMI on medications desires additional information about their illness, medications and potential side effects (C), they will often seek out accessible, easy-to-understand information from a variety of non-practitioner sources (eg, peers, internet) they perceive to be trustworthy and credible (O), due to need for increased knowledge (M), increased reassurance (M) and greater control (M) with respect to medication and life decisions. | 37 56 67 68 71 77 78 80 85 86 |
| CMOC 7: confiding and negotiating in a safe way When an SU with SMI on medications has continuity over time in a respectful, trusting therapeutic alliance with practitioners who openly discuss and make collaborative medication decisions with them, even when there are disagreements (C), they are more apt to confide in and to negotiate with their practitioners about their medication issues and management plans (O), due to a sense of safety with their practitioners (M), and increased belief (M) in themselves to manage their lives. | 38–40 42–44 46 48–50 54 56 58 61 62 67–69 71 72 74 78–81 83 84 89 91 92 94 115 |
| CMOC 8: perceived risks When SUs with SMI desire to taper, change or discontinue their medication regimen (C), their clinicians may resist sharing information with them and may not support them (O) because they judge that doing so may put themselves, the patient and others at risk (M) if adverse outcomes occur (eg, harm to self or others). | 40 42 45 55 76 83 86 88 90 93 94 |
| CMOC 9: family and social supports When an SU with SMI has support from family and social network members who believe in them and want the best for them (C), they are apt to feel more confident in following through with prescribed medication plans (O) due to increased belief (M) in their capacity to handle ongoing challenges and a sense of safety (M) among people looking after their well-being. | 54 57 61 64 66 72 73 84 86 |
| CMOC 10: fear and guilt When an SU with SMI is aware that their family members are fearful about the consequences from medication changes and want them to maintain medications as prescribed (C), they may continue on the medications against their will or secretly discontinue/change their medications (O) to avoid conflict (M) and/or withdrawal of their family’s support (M) for them. | 51 54 57 61 63 68 73 80 84 85 88 |
| CMOC 11: peer support workers When SUs with SMI have access to peer support workers with shared lived experiences who talk with them about SMI and life skills management, including medications and side effects (C), they are apt to experience a positive impact on their mental, physical and social-emotional health (O) because they feel validated (M) less stigmatised (M) and reassured (M) that they can have a productive, fulfilling lives with SMI. | 39 41 65 69 81 86 |
*Our lived experience group asked us to include ‘dehumanising’, based on their initial experiences with SMI diagnosis and management.