Sick Disturbed Helpless Hopeless Out of control Damaged or broken Substance abusing Unemployable Criminal Homeless Frightening Unhappy And other generally negative things!
Friends? Family? Clients? Neighbors? Are most hopeless, helpless, scary, & broken?
As many as 2/3 of people with serious mental illness get much better over the long term Level of illness severity today does not predict long- term outcome Access to rehabilitation services improves long term outcome The course of the illness varies greatly from person to person Medications & hospital time are important in managing symptoms but not strongly related to long term outcome People can have significant levels of control over their levels of happiness and recovery
People can and most do get better We can not predict who will do better so we need to do our best for everyone Everyone’s story and recovery is unique People have significant control of their lives and recovery The work that we do can support recovery There is real hope for recovery for everyone
“… a process of reclaiming one’s life after the catastrophe of mental illness” William Anthony
We go back to work We start seeing friends & family We pick up our hobbies We start doing household chores We go back to church We stop or modify therapy/counseling We have fun and enjoy life We Reclaim Our Lives & Start Living Again!!!
“It is only with the heart that one can see rightly; what is essential is invisible to the eye. “ -Antoine De Saint-Exupery-
“Anyone who understands jazz knows that you can't understand it. It's too complicated. That's what’s so simple about it…. That's why I can explain it. If I understood it, I wouldn’t know anything about it. “ -Yogi Berra-
Heartfelt & hopeful Passionate Warm & fuzzy Internal & personal Spiritual And almost impossible to define So how do we build a recovery services?
How do we operationalize a journey of the heart without killing it? How do we develop policy for things that are essential but invisible to the eye? How do we accredit things that you know are essential but can not define? How do you teach something that disappears in the explanation?
You have been diagnosed with a life threatening cancer. Without a crystal ball you can not be sure what treatment will be best. Do you bet on… Individual clinical judgment of a single oncologist? An informed synthesis of the best available research & practice?
Historically psychiatric rehab has focused on anecdotal & values oriented evidence. This is valuable but limited by: Variations in the intervention, population, system variables, and implementation issues Biases of observers Charisma of proponents (the family therapy school effect) Limited interest in and/or ability to replicate the work Reliance in poorly defined “models” to guide us Limited ability to systematically teach others how to do the work
“Employing clinical interventions that research has shown to be effective in helping consumers to recover and achieve their goals” Susan Azrin & Howard Goldman, 2005 EBP is simply the accumulated and tested wisdom of our growing experience, organized in a way that it can be shared and used by other providers Tony Zipple, 2006
“Physicians trained in evidence based techniques are better informed that their peers, even 15 years after graduating from medical school. Studies also show conclusively that patients receiving the care indicated by evidence based medicine experience better outcomes.” J. Pfeffer & R.Sutton, Harvard Business Journal (Jan. 2006)
n Intervention with a body of evidence: - Expert consensus - rigorous research studies & specified populations - specified client outcomes n Well defined intervention construct (treatment manual/fidelity scale) n Replication in many different settings n Evolution of the intervention and research as we learn
National group of leading mental health services researchers convened To identify interventions that qualify as EBPs To identify strategies to enhance implementation of EBPs Multiple funding sources (Johnson Foundation, SAMHSA, NASMHPD Research Institute)
National EBP Project: Implementing 6 EBPs 1.Integrated Dual Disorder Treatment 2.Illness Management and Recovery 3.Supported Employment 4.Family Psychoeducation 5.Assertive Community Treatment 6.Medication Management Approaches in Psychiatry
Focused on surrogate outcomes like good jobs, staying stable and in your life, etc. Minimize iatrogenic effects Embrace consumer choice Require ethical practitioner behavior Built on values of hope, respect, partnership They are the “head” that supports the “heart” of recovery
EBPs are not the only useful interventions, but using non-EBPs requires really good justification if an EBP exists for that area
Reduce symptoms of mental illness Minimize or prevent relapse of the illness Satisfy basic needs and enhance quality of life Improve functioning in normal adult roles (family, social, employment, etc.) Increase individual control and support recovery To lessen the family’s worry, concern and total responsibility for providing care - promote restoration of normal family relationships
Large impact on: Hospital use Housing Retention in treatment Moderate impact on: Symptoms & quality of life Weaker impact on: Employment Substance use Jail and legal problems Social adjustment
Stable housing Sober support network/family Regular meaningful activity Trusting clinical relationship Alverson et al, Com MHJ, 2000
Abstinence comes after supports in place Relapse comes after loss of supports Alverson et al, Com MHJ, 2000
Access to comprehensive services (e.g., employment, psychiatry, etc.) Social and family support interventions Long term perspective Cultural Sensitivity and competence Program fidelity
Integration of mental health and substance abuse treatment Same team of dually trained people Same location of services Both disorders treated at the same time Stage-wise treatment Different services are effective at different stages of treatment
Learn about mental illness and strategies for treatment Decrease symptoms Reduce relapses and hospitalizations Make progress toward consumer’s goals and recovery
Manualized, but tailored to needs of client CBT and motivational enhancement clinical techniques Weekly sessions About an hour but can be broken down for shorter/more frequent sessions Individual, group, or both Usually lasts 3 – 6 months In Indiana, adding peer specialist component in both training and site personnel
Recovery strategies Facts about mental illness Stress-vulnerability model and strategies for treatment Building social support Using medications effectively Reducing relapses Coping with stress Coping with symptoms and other problems Getting your needs met in the mental health system
Goal of competitive employment Rapid job search Integrating vocational and mental health services Consumer job preferences emphasized On-going, comprehensive assessment Time-unlimited support Employment is a priority
Place - train approach Jobs are transitions, keep trying until you find the right fit Developed for mental health centers Adopted in both rural and urban areas Caseloads of about 25 clients
Partnership/collaboration between Consumers Family or other support system Practitioners Building relationships/alliance Education: structured sessions CBT: Problem-solving, Skill-building Uses variety of formats (individual, group, home visits) Variety of materials (written, video, etc.)
Practical facts about mental illness New ways to manage illness To reduce tension and stress in families To provide social support and encouragement to consumer/each other To focus on future (not past) To find ways to help consumers in their recovery
Systematic and effective use of medications Involve consumers, family/support system, practitioners, supervisors, MHA in the decision-making process (not just prescriber) Strategies for medication adherence Guidelines and steps for decisions on medications Monitor results (and document) for future medication decisions Consumer’s needs and concerns are critical
Treat all symptoms with specific plan Monitor outcomes and adjust as necessary Use simplest regimen possible Documentation of side effects and treatments for side effects Clients seen every 3 months or more often during medication adjustments Clozapine offered to consumers with refractory psychosis
If someone is working…. (SE) If someone is managing their illness better… (WMR, Med Mgt) If someone has better family support…(Fam) If someone has good, flexible supports… (ACT) If someone is staying straight & sober… (IDDT) What are the odds that they are experiencing recovery?
Basis for public policy & funding decisions Basis for dissemination of useful practices Standardization makes teaching new staff easier Improves assessment of program quality Lets us know who it works with & who it does not work with Standardization allows for careful learning and evolution of practices
EBPs help us to more effectively help consumers to achieve recovery!
Founded 1959 Comprehensive, recovery focused “Present at the Creation” of psychiatric rehabilitation Long history of innovation 900 staff, 100 locations, 4 counties Many special services, serving many special populations 30 year old research department, now focused on recovery and EBPs
Integrated Dual Disorders Treatment (1998) Assertive Community Treatment (1979) Supported Employment (2000) Wellness Management & Recovery (2005) Evolving Practices… Cognitive Rehab, DBT, & CBT Integrated Health Care Forensic ACT Transition to Independence Program Supported Education
This is not easy stuff The challenge of change The challenge of resources The challenge of focus But our clients deserve our best A job Friends & family A good life on their terms How Do We Bridge This Gap?