Teaching Best Practices in an Evolving Science: Treating People with Co- Occurring Disorders 1

PRESENTERS Andrew L. Cherry, DSW, ACSW Oklahoma Endowed Professor of Mental Health, University of Oklahoma, School of Social Work, Tulsa Campus. Mary E. Dillon, MSW, Ed.D OK-COSIG Associate Evaluator Tulsa, OK. L. D. Barney, LADC St. Anthony's Hospital, Oklahoma City, OK & MSW Student, University of Oklahoma, Norman Campus. 2

Presentation Overview The presentation addresses issues relevant to social work practice and social work education raised by the President's New Freedom Commission report, which calls for a transformation in mental health and substance abuse care in the United States (Farkas, & Anthony, 2006). The President's New Freedom Commission report can be found at: 3

Primary Issues The primary issues for social work educators cluster around preparing students to participate and contribute to the transformation taking place in health care. How do we determine what to teach? What services and modalities meet the criteria of “best- practices?” More critical is the task of equipping students with skills to identify “best practices” as the science evolves throughout their professional career. 4

Best Practices = State-of-the-Art The concept of using "best practices" carries the connotation of being “state-of-the-art” treatment (Bushy, 2006). This presentation highlights research conducted over four years by the authors in the development, implementation, and evaluation of a state initiative to develop “best practice” services for people with co- occurring disorders. The development of “best practice” interventions that evolved from the mid 1990s and in particular since 2003—as a result of the SAMHSA Co-Occurring State Incentive Grant (COSIG)—provides a set of principals and approaches for identifying “best practices.” 5

Promising Practice & Evidence-Based Practice In the mental health and substance abuse literature, “Best Practices” tends to fall into two general categories: “promising practice” (empirically supported, consensus- based, direct practice techniques) and “evidence-based practice.” Promising practices are typically based on “practice wisdom” and studies that suggest such practices are safe and possibly effective. 6

Evidence-Based Practices Evidence-based practices are derived from research and meta-analyses. The procedures used in evidence-based practice are standardized and can be replicated. Evidence-based practices are characterized by the use of empirical research techniques (randomized controlled trials similar to those used to test medical interventions) to demonstrate that the evidence-based practice produces a positive outcome. And, there is ongoing objective evaluation of clinical cases to monitor the effectiveness of the evidence-based practice (Lakeman, 2008; Stuart, & Lilienfeld, 2007). 7

There is a Disconnect The primary issues for social work educators is related to preparing students to participate and contribute to the current transformation and future innovations. In part, this disconnect between Social Work education and the training needs of our students is responsible for the science to service lag reiterated by the Annapolis Coalition on the Behavioral Health Workforce in Their point was that it “takes well over a decade for proven interventions to make their way into practice, since prevention and treatment services are driven more by tradition than by science” (Glisson, 2007; Hoge, et al., 2007). 8

Bridging the Gap Social work educators are well positioned to bridge the gap between the training provided in schools of social work and workforce needs in the treatment community to provide best practice services, for example, for people with a co-occurring disorder. Teaching best practices, however, must include teaching students how to identify best practices as the science evolves (Mendel, et al., 2008). For most Social Work Faculty this means retooling our curricula. 9

Retooling Our Curricula First, Social Work curricula has not kept pace with the dramatic changes wrought by managed care, health care reforms, and presented here as and example, the ongoing transformation in the treatment for people with a co-occurring disorder. This lag of teaching current best practices has left our students unprepared for contemporary practice environments. It takes more than telling our students that best practices are out there. 10

Retooling Our Curricula (cont’d) Second, too many programs persist in using passive, didactic models of instructions that have been proven ineffective in changing practice patterns or improving healthcare outcomes. Third, consumers and their families, who play an enormous care-giving role, typically receive no educational support, nor is their considerable expertise about the lived experience of illness and recovery tapped by engaging them as educators of our students (Hoge & Morris, 2004). 11

Best Practices in Behavioral Health Education & Training Six recommendations for the “how, what, where, and who” of Social Work Education and Training: Best Practice 1: Professional social work training needs to instill an understanding of the competing paradigms of service delivery and the diverse scientific, economic, and social forces that shape healthcare and social services. 12

Recommendations (cont’d 2) Best Practice 2: Curricula are routinely updated to address the values, knowledge, and skills essential for practice in contemporary health and social service systems Best Practice 3: Best practice guidelines need to be used as teaching tools 13

Recommendations (cont’d 3) Best Practice 4: Teaching methods need to be evidence-based Best Practice 5: Social Work educators need to be knowledgeable and experienced in providing best practices in the delivery of healthcare and social services Best Practice 6: To deal with the evolving science, students need to learn the importance of engaging in lifelong learning (Hoge, Huey, & O’Connell, 2004). 14

“Underprepared from the Moment They Complete Their Training” “While the incidence of co-occurring mental and addictive disorders among individuals has increased dramatically, most of the workforce lacks the array of skills needed to assess and treat persons with these co- occurring conditions. Training and education programs largely have ignored the need to alter their curricula to address this problem, and, thus, the nation continues to prepare new members of the workforce who simply are underprepared from the moment they complete their training” (SAMHSA, 2007). 15

Impact of a Best Practice What is the outcome of a best practice that is taught to a community of clinicians? The results of the Oklahoma-COSIG evaluation is a case example. This is a comparative study of the outcome of 19,241 people who were treated in 15 co- occurring model programs that identified and implemented best practices and 5 control programs that used typical treatment. 16

Description of those Treated Age Differences: As a group people with an indication of a co-occurring disorder who enter treatment tended to be younger. Education: There was no significant difference in education among males; however, women with an indication of a co-occurring disorder had slightly less education than women without an indication of a co- occurring disorder. Income: The average yearly reported income for men admitted to treatment was $11,636, slightly higher than for women admitted for treatment ($10,648). The per capita income in Oklahoma in 2006 was $32,

Description of those Treated (cont’d 2) Homelessness: Both men and women with an indication of a co-occurring disorder were likely to be homeless. Among homeless people in this study sample approximately 50% were identified as having a co- occurring disorder. Admission Status: You can expect both men and women with a co-occurring disorder to be admitted as a result of a legal intervention. Arrests: Men and women with an indication of a co- occurring disorder will have had more arrests when entering treatment. Serious Mental Illness: People with a co-occurring disorder were less likely to be identified as having a serious mental disorder (men = 25%, women = 15%). 18

Outcomes Preliminary Findings: Differences between Model programs and Control programs on identifying people with a co-occurring disorder (N = 19,241). Model and Control Programs MEN No COD MEN COD Women No COD Women COD Model54.5%45.5%66.3%33.7% Control75.5%24.5%82.2%17.8% 19

Outcomes (cont’d 2) Preliminary Findings: Differences between Model programs and Control programs on Treatment Completion (N = 19,241). Model and Control Programs MEN No COD MEN COD Women No COD Women COD Model57.5%70.4%45%65.5% Control25.5%29%15%17% 20

Outcomes (cont’d 3) Preliminary Findings: Differences between Mental Health Model programs and Control programs on Days in Treatment (N = 19,241). Model and Control Programs MEN No COD MEN COD Women No COD Women COD Model Control

Outcomes (cont’d 4) Preliminary Findings: Differences between Substance Abuse TX Model programs and Control programs on Days in Treatment (N = 19,241). Model and Control Programs MEN No COD MEN COD Women No COD Women COD Model Control

Identifying Best Practices Teaching best practices, however, must include learning how to identify best practices and teaching students how to identify best practices in their careers as the science evolves (Mendel, et al., 2008). Our study and the literature suggests that there are three basic principals for identifying best practice interventions, services, and modalities in an evolving science. 23

Three Principals The first principal is “Do no harm.” There are evidence- based practices that are of low and high risk. Interventions that depend on cohesive techniques are more risky than collaborative techniques. The second principal is that evidence-based practices meet the value-based principals of social work practice. For instance, a best practice intervention must also be culturally appropriate. The third principal is that the intervention increases optimal outcomes for participants (Bushy, 2006; Petr & Walter, 2005). 24

Conclusion We teach to prepare our students for the world of social work practice. Like the world, however, the profession and our students are facing a rapidly changing practice landscape. This is problematic because: Social Work curricula has not kept pace with the dramatic changes in health care reforms, This lag of teaching current best practices has left our students unprepared for contemporary practice, 25

Conclusion (cont’d ) There are specific steps we need to take: We need to engage the expertise of consumers and families as educators of our students, Evidence-based practices must meet the value-based principals of social work practice, Best practice guidelines need to be used as teaching tools, To deal with the evolving science, faculty and students need to learn the importance of engaging in lifelong learning. 26

The End 27