Recovery Evidence Based Practices

1. Recovery & Evidence Based Practices Advocating For The Future Of Psychiatric Rehabilitation Tony Zipple, Sc.D, MBA CEO, Thresholds 773-572-5220 tzipple@thresholds.org www.thresholds.org

3. Generally We Think Sick Disturbed Helpless Hopeless Out of control Damaged or broken Substance abusing Unemployable Criminal Homeless Frightening Unhappy And other generally negative things!

4. Think Of Know People With Mental Illness Whom You Personally Know? Friends? Family? Clients? Neighbors? People here today in this room? Are most of them hopeless, helpless, scary, & broken most of the time?

5. What We Know About The Course Of Mental Illness 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 We do not know how to predict who gets better and who does not Access to rehabilitation services improves long term outcome

6. More On What We Know The course of the illness varies greatly from person to person Medications & hospital time are important in symptom management, but not strongly related to long-term outcome People have significant levels of control over their own levels of happiness and recovery

7. In Short People can, and most do, get better We can not predict who will get 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

8. There is hope for recovery for every person with a mental illness! (And I mean EVERY person)

9. Recovery Is Recognized By New Freedom Commission �We envision a future when everyone with a mental illness will recover�� But success is not guaranteed What do we mean by �recover�? Are we willing to spend the time and money to support recovery? What resources & tools do we need to realize this vision?

10. What Is Recovery � Recovery is a process of reclaiming one�s life after the catastrophe of mental illness� William Anthony

11. Recovery, Like Tragedy, Happens In Everyone�s Life Consider a time when something really bad happened in your life What happened What were you like in the weeks/months after the event How did you know when you were recovering from it? Did doing some things help? Did some things hurt? How did you survive the events?

12. People Are Resilient Recovery is a natural process seen following all traumatic events. And bad things happen to us all Over time, most people recover from the most tragic events even if their lives are different in the aftermath physical disabilities death of loved one war related losses loss of home etc.

13. �Recovery� is What Happens When We Bounce Back. It Is� Our own place in the world Peace of mind Friends & family Opportunities to grow and to be who we are Activities that provide genuine pleasure Authentic happiness A good life (though perhaps a different life)

14. Recovery Is Not� A cure Freedom from symptoms An end to problems Elimination of relapses A life like you originally planned But it can be a good, if different life

15. Recovery is A Journey Of The Heart �It is only with the heart that one can see rightly; what is essential is invisible to the eye.� -Antoine De Saint-Exupery-

16. Important Journeys, Like Recovery, Start With The Heart Heartfelt passion & compassion motivate us, inspires us, makes life worth living The heart leads us to places where we want to be The heart keeps us going during bad times

17. Matters Of The Heart Have No Clear Definition�Like Jazz � 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-

18. Recovery, As A �Heart� Matter, Is� Emotional & hopeful Passionate Warm & fuzzy Internal & personal Spiritual And almost impossible to define So how do we build a recovery services?

19. Consider The Program & Policy Challenges of Recovery How do we operationalize a journey of the heart without killing it? How do we develop public policy for things that are �essential but invisible to the eye�? How do we review & accredit things that we know are essential but can not define? How do we teach something that disappears in the explanation?

20. Evidence Based Practices A Toolkit For Making Recovery Real For Our Loved Ones

21. The Question You have been diagnosed with a life threatening cancer. You want your life back. 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?

22. How Do We Know What Works? Historically PSR has focused on �best clinical judgment.� This is valuable but limited by: Variations in the intervention, population, system variables, and implementation issues Biases of observers Charisma of proponents 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

23. The Result: Psychiatric Rehabilitation Is� Built on values and good intentions Based on political positioning Passed on through apprenticeship Generally, based on anecdotal experiences not well evaluated Not easily taught or disseminated Of very uneven quality or effectiveness for consumers It has not been based on standard interventions or systematic evaluation!

24. Fifty Years Ago, Clinical Judgment Was The Best We Had New mission New interventions Limited experience Little research Limited resources Little national infrastructure

25. Today We Have More Experience 20 years of supported housing 30 years of family psychoeducation 30 years of PACT & replications 40 years of community employment 50 years of clubhouse & replications 50 years of medication 60 years of peer support And far stronger national infrastructure We know a lot about what works well� and what does not work so well!

26. What Is Evidence Based Practice? �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, 2007

27. Extensive Data: EBP Superior To General Clinical Judgment Cognitive therapy for depression Systematic desensitization for phobias Dialectical Behavior Therapy Coronary bypass surgery Anesthesia malpractice rates Psychiatric medication algorithms Diabetes treatment algorithms Response to stroke Response to myocardial infarction Over 15,000 medical EBP articles have been published!

28. Summary Of Experience with Medical EBPs �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)

29. So Why Don�t We Use EPBs More Often In PSR? There is too much sometimes conflicting evidence There is not enough good evidence Our situation is always unique We like stories more than data Mostly, we like to think that our clinical judgment is better than research based interventions

30. Generally, People Are Not Fast Learners �If all we have is a hammer, every problem looks like a nail� Sometimes called the Simon & Garfunkel Principle: �A man hears what he wants to hear and disregards the rest� The Lake Wobegon Effect: �Where all the children are above average�

31. Evidence-Based Practice Is Simply A Way To Give The Best That We Have Intervention with a body of evidence: - Expert consensus - rigorous research studies & specified populations - specified client outcomes Well defined intervention construct (treatment manual/fidelity scale) Replication in many different settings Evolution of the intervention and research as we learn

32. All Of The SAMHSA EBPs Are Designed To Support Recovery Focused on surrogate outcomes like good jobs, staying stable and in your life, etc. Embrace consumer choice Requires ethical practitioner behavior Built on values of hope, respect, partnership They are the �head� that supports the �heart� of recovery

33. Summarizing The Last Half Hour� All of us have a natural inclination to recover All of us recover as we do things that help us to feel better� to recover Defining recovery is difficult Some interventions may work better that others at supporting recovery How do we help consumers do things that promote their recovery and avoid things that interfere with their recovery?

34. National EBP Project 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)

35. National EBP Project: Implementing 6 EBPs The Implementing Evidence-Based Practices Project is an initiative funded by the Robert Wood Johnson Foundation and the Substance Abuse and Mental Health Services Administration (SAMHSA). The major aim of this initiative is to provide training on evidence-based practices so they will become available to consumers who would benefit from them. Experts from universities and organizations around the country were brought together to develop materials to help mental health systems implement assertive community treatment and the other interventions listed above that research has demonstrated to be effective. The program you are working with is one of several in Indiana, New York, the Netherlands, and other areas that will be testing training materials for assertive community treatment. Throughout the next year, researchers and the developers of these materials will visit with you to get your views on the materials and to see how the program is doing. The materials developed for assertive community treatment are somewhat different than the materials developed for the other evidence-based practices. There is a brief introduction in the ACT Team Workbook and our training for each of the evidence-based practices shown on this slide. Developing expertise in all of the above practices is consistent with implementing ACT. Ask if anyone has questions about the Implementing Evidence-Based Practices Project.The Implementing Evidence-Based Practices Project is an initiative funded by the Robert Wood Johnson Foundation and the Substance Abuse and Mental Health Services Administration (SAMHSA). The major aim of this initiative is to provide training on evidence-based practices so they will become available to consumers who would benefit from them. Experts from universities and organizations around the country were brought together to develop materials to help mental health systems implement assertive community treatment and the other interventions listed above that research has demonstrated to be effective. The program you are working with is one of several in Indiana, New York, the Netherlands, and other areas that will be testing training materials for assertive community treatment. Throughout the next year, researchers and the developers of these materials will visit with you to get your views on the materials and to see how the program is doing. The materials developed for assertive community treatment are somewhat different than the materials developed for the other evidence-based practices. There is a brief introduction in the ACT Team Workbook and our training for each of the evidence-based practices shown on this slide. Developing expertise in all of the above practices is consistent with implementing ACT. Ask if anyone has questions about the Implementing Evidence-Based Practices Project.

36. Some Good Practices Are Not Yet Evidence Based Practices Clubhouse Supported Education Supported Housing Peer Support & Education Forensic ACT Aging services Case management

37. However, EBPs Are The Preferred Interventions Where They Exist! EBPs are not the only useful interventions, but using non-EBPs requires really good justification if an EBP exists for that area

38. Assertive Community Treatment (ACT)

39. Primary Goals of ACT Treatment 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 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

40. ACT Works � Much Of The Time 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

41. Integrated Dual Disorders Treatment (IDDT)

42. How do people obtain remission from dual disorders? Stable housing Sober support network/family Regular meaningful activity Trusting clinical relationship Alverson et al, Com MHJ, 2000 This slide is extremely important. This information comes from an intensive ethnographic study of persons with dual disorders. Alverson and his colleagues found that for people to recover, they need these four factors. What do you think came first, sobriety or these factors listed on this slide? These factors usually came first. This is important for all of us to recognize. If people remain in unsafe housing and have no sober supports and no job or other activity during the day, they are unlikely to get sober. We should NOT wait for people to get sober before we help them into safe housing and meaningful activities like work. If they do not obtain at least 2 of these factors, they are extremely unlikely to become sober. These are the factors that treatment services need to support. This slide is extremely important. This information comes from an intensive ethnographic study of persons with dual disorders. Alverson and his colleagues found that for people to recover, they need these four factors. What do you think came first, sobriety or these factors listed on this slide? These factors usually came first. This is important for all of us to recognize. If people remain in unsafe housing and have no sober supports and no job or other activity during the day, they are unlikely to get sober. We should NOT wait for people to get sober before we help them into safe housing and meaningful activities like work. If they do not obtain at least 2 of these factors, they are extremely unlikely to become sober. These are the factors that treatment services need to support.

43. Built On Non-Traditional Lessons Abstinence comes after supports in place Relapse comes after loss of supports Alverson et al, Com MHJ, 2000

44. Principles of Integrated Dual Disorder Treatment 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

45. Other Important IDDT Elements Access to comprehensive services (e.g., employment, psychiatry, etc.) Social and family support interventions Long term perspective Cultural Sensitivity and competence Program fidelity Training for rehabilitation of skills. Because dual disorders have such a devastating effect on people�s lives, they often need help rebuilding skills to live. Rehabilitation will focus on each person;s unique needs and may include living skills, social skills, leisure skills Social support interventions include working with a client to increase social support. Family work, groups, self help, social skills training all help increase social support for sobriety. See Drake, Wallach, Alverson and Mueser (2002) for a good summary of the reasons why it is important to help clients rebuild social networks and activities into their lives to support sobriety and recovery. Long term perspective. Because both disorders are chronic, taking a long term perspective is necessary to help people recover. Recovery occurs over months to years for most people. Cultural sensitivity and competence. Effective treatment addresses each client�s unique culture and needs. Program fidelity. As mentioned before, programs that do not follow these aspects of treatment aren�t as effective as programs that follow this model.Training for rehabilitation of skills. Because dual disorders have such a devastating effect on people�s lives, they often need help rebuilding skills to live. Rehabilitation will focus on each person;s unique needs and may include living skills, social skills, leisure skills Social support interventions include working with a client to increase social support. Family work, groups, self help, social skills training all help increase social support for sobriety. See Drake, Wallach, Alverson and Mueser (2002) for a good summary of the reasons why it is important to help clients rebuild social networks and activities into their lives to support sobriety and recovery. Long term perspective. Because both disorders are chronic, taking a long term perspective is necessary to help people recover. Recovery occurs over months to years for most people. Cultural sensitivity and competence. Effective treatment addresses each client�s unique culture and needs. Program fidelity. As mentioned before, programs that do not follow these aspects of treatment aren�t as effective as programs that follow this model.

46. Wellness (a.k.a. Illness) Management & Recovery

47. WMR Goals Learn about mental illness and strategies for treatment Decrease symptoms Reduce relapses and hospitalizations Make progress toward consumer�s goals and recovery

48. WMR Format 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 Beginning to add peer specialist component

49. WMR Content Areas 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

50. Supported Employment: Individualized Placement & Support

51. Supported Employment Goal of competitive employment Rapid job search Integrating vocational and mental health services Consumer job preferences emphasized On-going, comprehensive assessment Time-unlimited support Vocational generalists

52. Supported Employment 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 60-80% success rates Long term, broad impact

53. Family Psychoeducation

54. Family Psychoeducation 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.)

55. Families and consumers learn� 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

56. Medication Management

57. Medication Management 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

58. Medication Management: Some specific examples 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 or dual disorders

59. EBPs Seem To Support Recovery 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?

60. Importance Of Evidence Based Practice 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

61. And The Bottom Line EBPs help us to more effectively help consumers to achieve recovery!

62. What Can Families Do To Support EBPs? Get smart and stay current about the best interventions Help your loved one to ask for EBPs by name Ask about fidelity scores Demand that payers support EBPs Support provider use of EBPs Advocate for funding for EBPs

63. Evidence Based Practices Increase The Odds Of Recovery� �And Your Loved One Deserves The Best Chance To Recover!

64. Don�t Agonize� Organize!It�s not about waiting for the storm to pass, but about learning to dance in the rainThank You!